Example: BSJ2 Transition of Care Bundle - PACIO Transitions of Care Implementation Guide v1.0.0

PACIO Transitions of Care Implementation Guide
1.0.0 - STU 1 US

PACIO Transitions of Care Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-transitions-of-care-ig/ and changes regularly. See the Directory of published versions

Example Bundle: Example: BSJ2 Transition of Care Bundle

Document Details

Profile: Transition of Care Bundle

Final Document at 2024-05-10 08:49:58-0400 by Practitioner Judy Salas for Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH26)

Document Subject

Last updated: 2021-03-29 14:25:34-0500; Language: en-US

Profile: US Core Patient Profile version: 8.0.1

Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH26)

Active:

true

Marital Status:

unknown

Other Id:

Medical Record Number/1032702A (use: usual, )

Contact Detail

ph: 555-555-5555(Home)
ph: (410) 444-5555
111 Maple Ct, Grand Rapids, MI 49503

Language:

English (preferred)

son:

Charles Johnson
111 Maple Ct, Grand Rapids, MI 49503
ph: (210) 222-3333

daughter:

Debra Johnson
333 W. Camden St., Baltimore, MD 21201
ph: (410) 444-5555

US Core Race Extension:

ombCategory: Race & Ethnicity - CDC: 2106-3 (White)
text: White

Document Content

Advance directives for Betsy Smith-Johnson

List of allergies for Betsy Smith-Johnson

Allergies for Betsy Smith-Johnson

Behavioral health information for Betsy Smith-Johnson

Functional status of Betsy Smith-Johnson

List of immunizations for Betsy Smith-Johnson

Discharge instructions for Betsy Smith-Johnson

List of medical equipment needed by Betsy Smith-Johnson

List of medications prescribed for Betsy Smith-Johnson

Discharge care plan for Betsy Smith-Johnson

List of problem conditions and observations for Betsy Smith-Johnson

List of procedures prescribed for Betsy Smith-Johnson

Reason for referring Betsy Smith-Johnson

List of test results for Betsy Smith-Johnson

Social history for Betsy Smith-Johnson

Vital signs for Betsy Smith-Johnson

Additional Resources Included in Document

Entry 2 - fullUrl = http://www.example.org/fhir/Patient/Example-Smith-Johnson-Patient2

Resource Patient:

Last updated: 2021-03-29 14:25:34-0500; Language: en-US
Profile: US Core Patient Profile version: 8.0.1
Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH26)
Active: true Marital Status: unknown
Other Id: Medical Record Number/1032702A (use: usual, )
Contact Detail
ph: 555-555-5555(Home)
ph: (410) 444-5555
111 Maple Ct, Grand Rapids, MI 49503
Language: English (preferred)
son:
Charles Johnson
111 Maple Ct, Grand Rapids, MI 49503
ph: (210) 222-3333
daughter:
Debra Johnson
333 W. Camden St., Baltimore, MD 21201
ph: (410) 444-5555
US Core Race Extension:
ombCategory: Race & Ethnicity - CDC: 2106-3 (White)
text: White

Entry 3 - fullUrl = http://www.example.org/fhir/Condition/BSJ2-DepressionDiagnosis

Resource Condition:

Profile: US Core Condition Encounter Diagnosis Profile version: 8.0.1
Condition Asserted Date: 2005-02
clinicalStatus: Active
verificationStatus: Confirmed
category: Encounter Diagnosis
code: Depressive disorder (disorder)
bodySite: Brain structure (body structure)
subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH26)

Entry 4 - fullUrl = http://www.example.org/fhir/Condition/BSJ2-DiabetesDiagnosis

Resource Condition:

Profile: US Core Condition Encounter Diagnosis Profile version: 8.0.1
Condition Asserted Date: 2017-06
clinicalStatus: Active
verificationStatus: Confirmed
category: Encounter Diagnosis
code: Diabetes mellitus type 2 in nonobese (disorder)
bodySite: Structure of endocrine system (body structure)
subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH26)
onset: 2017-06
recordedDate: 2017-06-05

Entry 5 - fullUrl = http://www.example.org/fhir/Condition/BSJ2-HyperlipidemiaDiagnosis

Resource Condition:

Profile: US Core Condition Encounter Diagnosis Profile version: 8.0.1
Condition Asserted Date: 2018-06
clinicalStatus: Active
verificationStatus: Confirmed
category: Encounter Diagnosis
code: Hyperlipidemia (disorder)
bodySite: Structure of cardiovascular system (body structure)
subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH26)

Entry 6 - fullUrl = http://www.example.org/fhir/Condition/BSJ2-ProblemList-PressureInjury

Resource Condition:

Profile: US Core Condition Problems and Health Concerns Profile version: 8.0.1
clinicalStatus: Active
verificationStatus: Confirmed
category: Problem List Item
code: Pressure injury of left hip stage II (disorder)
subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH26)
recordedDate: 2024-04-27 15:40:00-0400

Entry 7 - fullUrl = http://www.example.org/fhir/Observation/BSJ2-ADL-Mobility

Resource Observation:

Profile: US Core Simple Observation Profile version: 8.0.1
Event Location: Location Motown Home Health Facility
status: Final
category: Functional Status
code: Need help getting out of bed, showered, or dressed
subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH26)
effective: 2024-05-16 14:30:00-0400
performer: PractitionerRole Occupational Therapist
value: Yes

Entry 8 - fullUrl = http://www.example.org/fhir/Device/BSJ2-Device-WoundPump

Resource Device:

type: Negative-pressure wound therapy system pump (physical object)

Entry 9 - fullUrl = http://www.example.org/fhir/Device/BSJ2-Device-Wheelchair

Resource Device:

type: Wheelchair device (physical object)

Entry 10 - fullUrl = http://www.example.org/fhir/List/BSJ2-SMPMedList

Resource List:

Profile: Standardized Medication Profile - Medication List
Home Health Medication List
Date: 2024-08-11 Mode: Working List Status: Current Code: Patient generated medication list [Identifier] Episode Pharmacy
Subject: Betsy Smith-JohnsonSource:
Items Date
atorvastatin 40 MG Oral Tablet 2024-08-11
sertraline 25 MG Oral Tablet 2024-08-11
empagliflozin 10 MG Oral Tablet [Jardiance] 2024-08-11

Entry 11 - fullUrl = http://www.example.org/fhir/MedicationStatement/BSJ2-SMPMedStmt1

Resource MedicationStatement:

Profile: Standardized Medication Profile - MedicationStatement
status: active
status: Recorded
subject: Betsy Smith-Johnson
dateAsserted: 2024-08-11
informationSource: Judy Salas, DNP
Dosages
- Sequence Text
* 1 po nightly

Entry 12 - fullUrl = http://www.example.org/fhir/MedicationStatement/BSJ2-SMPMedStmt4

Resource MedicationStatement:

Profile: Standardized Medication Profile - MedicationStatement
status: active
status: Recorded
subject: Betsy Smith-Johnson
dateAsserted: 2024-08-11
informationSource: Judy Salas, DNP
Dosages
- Sequence Text
* 1 po once daily

Entry 13 - fullUrl = http://www.example.org/fhir/MedicationStatement/BSJ2-SMPMedStmt9

Resource MedicationStatement:

Profile: Standardized Medication Profile - MedicationStatement
status: active
status: Recorded
subject: Betsy Smith-Johnson
dateAsserted: 2024-08-11
informationSource: Judy Salas, DNP
Dosages
- Sequence Text
* 1 po nightly

Entry 14 - fullUrl = http://www.example.org/fhir/MedicationRequest/BSJ2-SMPMedReq1

Resource MedicationRequest:

Profile: US Core MedicationRequest Profile
status: Active
intent: Order
subject: Betsy Smith-Johnson
authoredOn: 2024-08-11
requester: Judy Salas, DNP
DosageInstructions
- Sequence Text
* 1 po nightly

Entry 15 - fullUrl = http://www.example.org/fhir/MedicationRequest/BSJ2-SMPMedReq4

Resource MedicationRequest:

Profile: US Core MedicationRequest Profile
status: Active
intent: Order
subject: Betsy Smith-Johnson
authoredOn: 2024-08-11
requester: Judy Salas, DNP
DosageInstructions
- Sequence Text
* 1 po once daily

Entry 16 - fullUrl = http://www.example.org/fhir/MedicationRequest/BSJ2-SMPMedReq9

Resource MedicationRequest:

Profile: US Core MedicationRequest Profile
status: Active
intent: Order
subject: Betsy Smith-Johnson
authoredOn: 2024-08-11
requester: Judy Salas, DNP
DosageInstructions
- Sequence Text
* 1 once daily

Entry 17 - fullUrl = http://www.example.org/fhir/CarePlan/BSJ2-DischargeCarePlan

Resource CarePlan:

Profile: US Core CarePlan Profile version: 8.0.1
status: Active
intent: Plan
category: Assessment and Plan of Treatment
subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH16)
activity
activity
activity
activity
activity

Entry 18 - fullUrl = http://www.example.org/fhir/ServiceRequest/BSJ2-PCPFollowUp

Resource ServiceRequest:

Profile: US Core ServiceRequest Profile version: 8.0.1
status: Active
intent: Order
category: Evaluation procedure (procedure)
priority: Routine
code: No display for ServiceRequest.code (concept: Follow-up visit (procedure))
subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH26)
occurrence: 2024-05-28
authoredOn: 2024-05-18
requester: PractitionerRole Emergency Medicine Physician

Entry 19 - fullUrl = http://www.example.org/fhir/Location/org-Loc-ED-Metro-Hospital

Resource Location:

status: Active
name: Metro Hospital Emergency Department
address: 22327 Moross Rd, Detroit, MI 48236

Entry 20 - fullUrl = http://www.example.org/fhir/Organization/org-HomeHealth-Motown

Resource Organization:

Profile: US Core Organization Profile version: 8.0.1
active: true
name: Motown Home Health Grand Rapids
Contacts
- Telecom Address
* ph: (210) 555-2882 121 Spruce Dr. Grand Rapids, MI 49503

Entry 21 - fullUrl = http://www.example.org/fhir/Practitioner/Practitioner-JudySalas

Resource Practitioner:

version: 4; Last updated: 2024-09-21 14:11:15+0000
identifier: http://example.org/fhir/MI-state-license/480410286
active: true
name: Judy Salas
telecom: ph: (555) 944-2454, jsalas@MotownHHA.com
gender: Female
address: 17010 Harper Ave, Detroit, MI 48224

Entry 22 - fullUrl = http://www.example.org/fhir/Practitioner/Practitioner-PriyaSarkar

Resource Practitioner:

version: 4; Last updated: 2024-09-21 14:11:15+0000
identifier: United States National Provider Identifier/4362436261
active: true
name: Priya Sarkar
telecom: ph: (555) 375-3777, psarkar@MetroHospital.com
gender: Female
address: 22327 Moross Rd, Detroit, MI 48236

Entry 23 - fullUrl = http://www.example.org/fhir/PractitionerRole/PractitionerRole-Physician-PriyaSarkar

Resource PractitionerRole:

active: true
practitioner: Priya Sarkar
organization: Metro Hospital Emergency Department
code: Emergency Medicine Physician
location: Location Metro Hospital Emergency Department

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IG © 2024+ HL7 International / Patient Care. Package hl7.fhir.us.pacio-toc#1.0.0 based on FHIR 4.0.1. Generated 2026-05-17
Links: Table of Contents | QA Report | Version History | | Propose a change

Date: 2024-08-11	Mode: Working List	Status: Current	Code: Patient generated medication list [Identifier] Episode Pharmacy
Subject: Betsy Smith-JohnsonSource: