PACIO Transitions of Care Implementation Guide
1.0.0 - STU 1
PACIO Transitions of Care Implementation Guide
1.0.0 - STU 1
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
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<system value="http://www.example.org/documents"/>
<value value="12345"/>
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<type value="transaction"/>
<timestamp value="2024-05-10T14:25:34.001-05:00"/>
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<div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US"><a name="Composition_JF-TOCComposition2"> </a><p class="res-header-id"><b>Generated Narrative: Composition JF-TOCComposition2</b></p><a name="JF-TOCComposition2"> </a><a name="hcJF-TOCComposition2"> </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">Language: en-US</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-TOC-Composition.html">Transition of Care Composition</a></p></div><p><b>identifier</b>: <code>http://example.org/GoodHealthClinic/id</code>/76053988-543c-4681-9a90-2f2eb9a7836c-CCDA-CCD</p><p><b>status</b>: Final</p><p><b>type</b>: <span title="Codes:{http://loinc.org 11490-0}">Physician Discharge summary</span></p><p><b>date</b>: 2024-05-10 08:49:58-0400</p><p><b>author</b>: <a href="Bundle-Example-JF-TOCBundle2.html#https-//gw.interop.community/pacior4test/open/Practitioner/Practitioner-JudySalas">Practitioner Judy Salas</a></p><p><b>title</b>: Transitions of Care Document for Jane Fiction</p><p><b>custodian</b>: <a href="Bundle-Example-JF-TOCBundle2.html#https-//gw.interop.community/pacior4test/open/Organization/org-HomeHealth-Motown">Organization Motown Home Health Grand Rapids</a></p></div>
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<display value="Physician Discharge summary"/>
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<date value="2024-05-10T08:49:58.313-04:00"/>
<author>
<reference
value="https://gw.interop.community/pacior4test/open/Practitioner/Practitioner-JudySalas"/>
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<title value="Transitions of Care Document for Jane Fiction"/>
<custodian>
<reference
value="https://gw.interop.community/pacior4test/open/Organization/org-HomeHealth-Motown"/>
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<section>
<title value="Advance directives for Jane Fiction"/>
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<coding>
<system value="http://loinc.org"/>
<code value="42348-3"/>
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<div xmlns="http://www.w3.org/1999/xhtml">Advance directives for Jane Fiction</div>
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<section>
<title value="List of allergies for Jane Fiction"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="48765-2"/>
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<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml">Allergies for Jane Fiction</div>
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<code value="nilknown"/>
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<section>
<title value="Behavioral health information for Jane Fiction"/>
<code>
<coding>
<system
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<code value="behavioral_health_summary"/>
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<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml">Behavioral health information for Jane Fiction</div>
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<system
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<code value="withheld"/>
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<section>
<title value="Functional status of Jane Fiction"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="47420-5"/>
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<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml">Functional status of Jane Fiction</div>
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<coding>
<system
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<code value="nilknown"/>
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<section>
<title value="List of immunizations for Jane Fiction"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11369-6"/>
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<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml">List of immunizations for Jane Fiction</div>
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<code value="nilknown"/>
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<section>
<title value="Discharge instructions for Jane Fiction"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="69730-0"/>
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<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml">Discharge instructions for Jane Fiction</div>
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<emptyReason>
<coding>
<system
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<code value="nilknown"/>
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<section>
<title value="List of medical equipment needed by Jane Fiction"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="46264-8"/>
</coding>
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<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml">List of medical equipment needed by Jane Fiction</div>
</text>
<entry>
<reference
value="https://gw.interop.community/pacior4test/open/Device/JF-Device-Wheelchair"/>
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</section>
<section>
<title value="Medications prescribed for Jane Fiction"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10160-0"/>
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<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml">List of medications prescribed for Jane Fiction</div>
</text>
<entry>
<reference
value="https://gw.interop.community/pacior4test/open/MedicationRequest/JF-SMPMedReq1"/>
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</section>
<section>
<title value="Discharge care plan for Jane Fiction"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="18776-5"/>
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<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml">Discharge care plan for Jane Fiction</div>
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<entry>
<reference
value="https://gw.interop.community/pacior4test/open/CarePlan/JF-DischargeCarePlan"/>
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</section>
<section>
<title
value="List of problem conditions and observations for Jane Fiction"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11450-4"/>
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<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml">List of problem conditions and observations for Jane Fiction</div>
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<entry>
<reference
value="https://gw.interop.community/pacior4test/open/Condition/JF-HyperlipidemiaDiagnosis"/>
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</section>
<section>
<title value="List of procedures prescribed for Jane Fiction"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="47519-4"/>
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<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml">List of procedures prescribed for Jane Fiction</div>
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<section>
<title value="Reason for referring Jane Fiction"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="42349-1"/>
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<text>
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<div xmlns="http://www.w3.org/1999/xhtml">Reason for referring Jane Fiction</div>
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<coding>
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<code value="nilknown"/>
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</section>
<section>
<title value="List of test results for Jane Fiction"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="30954-2"/>
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<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml">List of test results for Jane Fiction</div>
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<code value="nilknown"/>
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<section>
<title value="Social history for Jane Fiction"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="29762-2"/>
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<div xmlns="http://www.w3.org/1999/xhtml">Social history for Jane Fiction</div>
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<section>
<title value="Vital signs for Jane Fiction"/>
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<coding>
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<div xmlns="http://www.w3.org/1999/xhtml">Vital signs for Jane Fiction</div>
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<entry>
<fullUrl
value="https://gw.interop.community/pacior4test/open/Patient/Example-Fiction"/>
<resource>
<Patient>
<id value="Example-Fiction"/>
<meta>
<lastUpdated value="2021-03-29T14:25:34.001-05:00"/>
<profile
value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|8.0.1"/>
</meta>
<language value="en-US"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US"><a name="Patient_Example-Fiction"> </a><p class="res-header-id"><b>Generated Narrative: Patient Example-Fiction</b></p><a name="Example-Fiction"> </a><a name="hcExample-Fiction"> </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">Last updated: 2021-03-29 14:25:34-0500; Language: en-US</p><p style="margin-bottom: 0px">Profile: <a href="http://hl7.org/fhir/us/core/STU8.0.1/StructureDefinition-us-core-patient.html">US Core Patient Profile</a> version: 8.0.1</p></div><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;">Jane Fiction Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH26)</p><hr/><table class="grid"><tr><td style="background-color: #f3f5da" title="Record is active">Active:</td><td>true</td><td style="background-color: #f3f5da" title="Known Marital status of Patient">Marital Status:</td><td colspan="3"><span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-NullFlavor UNK}">unknown</span></td></tr><tr><td style="background-color: #f3f5da" title="Other Id (see the one above)">Other Id:</td><td colspan="3">Medical Record Number/1032702A (use: usual, )</td></tr><tr><td style="background-color: #f3f5da" title="Ways to contact the Patient">Contact Detail</td><td colspan="3"><ul><li>ph: 555-555-5555(Home)</li><li>ph: (410) 444-5555</li><li>111 Maple Ct, Grand Rapids, MI 49503</li></ul></td></tr><tr><td style="background-color: #f3f5da" title="Language spoken">Language:</td><td colspan="3"><span title="Codes:{urn:ietf:bcp:47 en}">English</span> (preferred)</td></tr><tr><td style="background-color: #f3f5da" title="Nominated Contact: son">son:</td><td colspan="3"><ul><li>Charles Fiction</li><li>111 Maple Ct, Grand Rapids, MI 49503</li><li>ph: (210) 222-3333</li></ul></td></tr><tr><td style="background-color: #f3f5da" title="Nominated Contact: daughter">daughter:</td><td colspan="3"><ul><li>Debra Fiction</li><li>333 W. Camden St., Baltimore, MD 21201</li><li>ph: (410) 444-5555</li></ul></td></tr><tr><td style="background-color: #f3f5da" title="Concepts classifying the person into a named category of humans sharing common history, traits, geographical origin or nationality. The race codes used to represent these concepts are based upon the [Race & Ethnicity - CDC (CDCREC)](https://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.840.1.113883.6.238) code system. Detailed race concepts are grouped by and pre-mapped to the 5 OMB race categories:
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or Other Pacific Islander
- White.">US Core Race Extension:</td><td colspan="3"><ul><li>ombCategory: <a href="http://hl7.org/fhir/us/core/STU4/CodeSystem-cdcrec.html#cdcrec-2106-3">Race & Ethnicity - CDC: 2106-3</a> (White)</li><li>text: White</li></ul></td></tr></table></div>
</text>
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<system value="urn:oid:2.16.840.1.113883.6.238"/>
<code value="2106-3"/>
<display value="White"/>
</valueCoding>
</extension>
<extension url="text">
<valueString value="White"/>
</extension>
</extension>
<identifier>
<use value="usual"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="MR"/>
<display value="Medical Record Number"/>
</coding>
<text value="Medical Record Number"/>
</type>
<system value="http://hospital.example.org"/>
<value value="1032702A"/>
</identifier>
<identifier>
<system value="http://hl7.org/fhir/sid/us-medicare"/>
<value value="1AA3D58WH26"/>
</identifier>
<active value="true"/>
<name>
<use value="usual"/>
<text value="Jane Fiction"/>
<family value="Fiction"/>
<given value="Jane"/>
</name>
<telecom>
<system value="phone"/>
<value value="555-555-5555"/>
<use value="home"/>
</telecom>
<telecom>
<system value="phone"/>
<value value="(410) 444-5555"/>
</telecom>
<gender value="female"/>
<birthDate value="1958-11-01"/>
<address>
<text value="111 Maple Ct, Grand Rapids, MI 49503"/>
<line value="111 Maple Ct"/>
<city value="Grand Rapids"/>
<state value="MI"/>
<postalCode value="49503"/>
<country value="US"/>
<period>
<start value="2016-12-06"/>
</period>
</address>
<maritalStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/>
<code value="UNK"/>
</coding>
</maritalStatus>
<contact>
<relationship>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-RoleCode"/>
<code value="SONC"/>
</coding>
</relationship>
<name>
<text value="Charles Fiction"/>
</name>
<telecom>
<system value="phone"/>
<value value="(210) 222-3333"/>
</telecom>
<address>
<text value="111 Maple Ct, Grand Rapids, MI 49503"/>
</address>
</contact>
<contact>
<relationship>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-RoleCode"/>
<code value="DAUC"/>
</coding>
</relationship>
<name>
<text value="Debra Fiction"/>
</name>
<telecom>
<system value="phone"/>
<value value="(410) 444-5555"/>
</telecom>
<address>
<text value="333 W. Camden St., Baltimore, MD 21201"/>
</address>
</contact>
<communication>
<language>
<coding>
<system value="urn:ietf:bcp:47"/>
<code value="en"/>
<display value="English"/>
</coding>
</language>
<preferred value="true"/>
</communication>
</Patient>
</resource>
<request>
<method value="PUT"/>
<url value="Patient/Example-Fiction"/>
</request>
</entry>
<entry>
<fullUrl
value="https://gw.interop.community/pacior4test/open/Condition/JF-HyperlipidemiaDiagnosis"/>
<resource>
<Condition>
<id value="JF-HyperlipidemiaDiagnosis"/>
<meta>
<profile
value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-encounter-diagnosis|8.0.1"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Condition_JF-HyperlipidemiaDiagnosis"> </a><p class="res-header-id"><b>Generated Narrative: Condition JF-HyperlipidemiaDiagnosis</b></p><a name="JF-HyperlipidemiaDiagnosis"> </a><a name="hcJF-HyperlipidemiaDiagnosis"> </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"/><p style="margin-bottom: 0px">Profile: <a href="http://hl7.org/fhir/us/core/STU8.0.1/StructureDefinition-us-core-condition-encounter-diagnosis.html">US Core Condition Encounter Diagnosis Profile</a> version: 8.0.1</p></div><p><b>Condition Asserted Date</b>: 2018-06</p><p><b>clinicalStatus</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/condition-clinical active}">Active</span></p><p><b>verificationStatus</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/condition-ver-status confirmed}">Confirmed</span></p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/condition-category encounter-diagnosis}">Encounter Diagnosis</span></p><p><b>code</b>: <span title="Codes:{http://snomed.info/sct 55822004}">Hyperlipidemia (disorder)</span></p><p><b>bodySite</b>: <span title="Codes:{http://snomed.info/sct 113257007}">Structure of cardiovascular system (body structure)</span></p><p><b>subject</b>: <a href="Patient-Example-Fiction.html">Jane Fiction Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH26)</a></p><p><b>asserter</b>: <a href="Practitioner-Practitioner-JudySalas.html">Practitioner Judy Salas</a></p></div>
</text>
<extension
url="http://hl7.org/fhir/StructureDefinition/condition-assertedDate">
<valueDateTime value="2018-06"/>
</extension>
<clinicalStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
<code value="active"/>
</coding>
</clinicalStatus>
<verificationStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/condition-ver-status"/>
<code value="confirmed"/>
</coding>
</verificationStatus>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/condition-category"/>
<code value="encounter-diagnosis"/>
<display value="Encounter Diagnosis"/>
</coding>
</category>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="55822004"/>
<display value="Hyperlipidemia (disorder)"/>
</coding>
</code>
<bodySite>
<coding>
<system value="http://snomed.info/sct"/>
<code value="113257007"/>
<display
value="Structure of cardiovascular system (body structure)"/>
</coding>
</bodySite>
<subject>🔗
<reference value="Patient/Example-Fiction"/>
</subject>
<asserter>🔗
<reference value="Practitioner/Practitioner-JudySalas"/>
</asserter>
</Condition>
</resource>
<request>
<method value="PUT"/>
<url value="Condition/JF-HyperlipidemiaDiagnosis"/>
</request>
</entry>
<entry>
<fullUrl
value="https://gw.interop.community/pacior4test/open/Device/JF-Device-Wheelchair"/>
<resource>
<Device>
<id value="JF-Device-Wheelchair"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Device_JF-Device-Wheelchair"> </a><p class="res-header-id"><b>Generated Narrative: Device JF-Device-Wheelchair</b></p><a name="JF-Device-Wheelchair"> </a><a name="hcJF-Device-Wheelchair"> </a><h3>DeviceNames</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Name</b></td><td><b>Type</b></td></tr><tr><td style="display: none">*</td><td>Wheelchair</td><td>User Friendly name</td></tr></table><p><b>type</b>: <span title="Codes:{http://snomed.info/sct 58938008}">Wheelchair device (physical object)</span></p></div>
</text>
<deviceName>
<name value="Wheelchair"/>
<type value="user-friendly-name"/>
</deviceName>
<type>
<coding>
<system value="http://snomed.info/sct"/>
<code value="58938008"/>
<display value="Wheelchair device (physical object)"/>
</coding>
</type>
</Device>
</resource>
<request>
<method value="PUT"/>
<url value="Device/JF-Device-Wheelchair"/>
</request>
</entry>
<entry>
<fullUrl
value="https://gw.interop.community/pacior4test/open/MedicationRequest/JF-SMPMedReq1"/>
<resource>
<MedicationRequest>
<id value="JF-SMPMedReq1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="MedicationRequest_JF-SMPMedReq1"> </a><p class="res-header-id"><b>Generated Narrative: MedicationRequest JF-SMPMedReq1</b></p><a name="JF-SMPMedReq1"> </a><a name="hcJF-SMPMedReq1"> </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"/><p style="margin-bottom: 0px">Profile: <a href="http://hl7.org/fhir/us/core/STU9/StructureDefinition-us-core-medicationrequest.html">US Core MedicationRequest Profile</a></p></div><p><b>status</b>: Active</p><p><b>intent</b>: Order</p><p><b>medication</b>: <span title="Codes:{http://www.nlm.nih.gov/research/umls/rxnorm 617311}">atorvastatin 40 MG Oral Tablet</span></p><p><b>subject</b>: <a href="Patient-Example-Fiction.html">Jane Fiction</a></p><p><b>authoredOn</b>: 2024-08-11</p><p><b>requester</b>: <a href="Practitioner-Practitioner-JudySalas.html">Judy Salas, DNP</a></p><p><b>reasonCode</b>: <span title="Codes:{http://snomed.info/sct 55822004}">Hyperlipidemia</span></p><h3>DosageInstructions</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Text</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>po nightly</td></tr></table></div>
</text>
<status value="active"/>
<intent value="order"/>
<medicationCodeableConcept>
<coding>
<system value="http://www.nlm.nih.gov/research/umls/rxnorm"/>
<code value="617311"/>
<display value="atorvastatin 40 MG Oral Tablet"/>
</coding>
</medicationCodeableConcept>
<subject>🔗
<reference value="Patient/Example-Fiction"/>
<display value="Jane Fiction"/>
</subject>
<authoredOn value="2024-08-11"/>
<requester>🔗
<reference value="Practitioner/Practitioner-JudySalas"/>
<display value="Judy Salas, DNP"/>
</requester>
<reasonCode>
<coding>
<system value="http://snomed.info/sct"/>
<code value="55822004"/>
<display value="Hyperlipidemia"/>
</coding>
</reasonCode>
<dosageInstruction>
<sequence value="1"/>
<text value="po nightly"/>
</dosageInstruction>
</MedicationRequest>
</resource>
<request>
<method value="PUT"/>
<url value="MedicationRequest/JF-SMPMedReq1"/>
</request>
</entry>
<entry>
<fullUrl
value="https://gw.interop.community/pacior4test/open/CarePlan/JF-DischargeCarePlan"/>
<resource>
<CarePlan>
<id value="JF-DischargeCarePlan"/>
<meta>
<profile
value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-careplan|8.0.1"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="CarePlan_JF-DischargeCarePlan"> </a><p class="res-header-id"><b>Generated Narrative: CarePlan JF-DischargeCarePlan</b></p><a name="JF-DischargeCarePlan"> </a><a name="hcJF-DischargeCarePlan"> </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"/><p style="margin-bottom: 0px">Profile: <a href="http://hl7.org/fhir/us/core/STU8.0.1/StructureDefinition-us-core-careplan.html">US Core CarePlan Profile</a> version: 8.0.1</p></div><p><b>status</b>: Active</p><p><b>intent</b>: Plan</p><p><b>category</b>: <span title="Codes:{http://hl7.org/fhir/us/core/CodeSystem/careplan-category assess-plan}">Assessment and Plan of Treatment</span></p><p><b>subject</b>: <a href="Patient-Example-Fiction.html">Jane Fiction Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH26)</a></p><h3>Activities</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Reference</b></td></tr><tr><td style="display: none">*</td><td><a href="ServiceRequest-JF-PCPFollowUp.html">ServiceRequest Follow-up visit (procedure)</a></td></tr></table></div>
</text>
<status value="active"/>
<intent value="plan"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/core/CodeSystem/careplan-category"/>
<code value="assess-plan"/>
<display value="Assessment and Plan of Treatment"/>
</coding>
</category>
<subject>🔗
<reference value="Patient/Example-Fiction"/>
</subject>
<activity>
<reference>🔗
<reference value="ServiceRequest/JF-PCPFollowUp"/>
</reference>
</activity>
</CarePlan>
</resource>
<request>
<method value="PUT"/>
<url value="CarePlan/JF-DischargeCarePlan"/>
</request>
</entry>
<entry>
<fullUrl
value="https://gw.interop.community/pacior4test/open/ServiceRequest/JF-PCPFollowUp"/>
<resource>
<ServiceRequest>
<id value="JF-PCPFollowUp"/>
<meta>
<profile
value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-servicerequest|8.0.1"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="ServiceRequest_JF-PCPFollowUp"> </a><p class="res-header-id"><b>Generated Narrative: ServiceRequest JF-PCPFollowUp</b></p><a name="JF-PCPFollowUp"> </a><a name="hcJF-PCPFollowUp"> </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"/><p style="margin-bottom: 0px">Profile: <a href="http://hl7.org/fhir/us/core/STU8.0.1/StructureDefinition-us-core-servicerequest.html">US Core ServiceRequest Profile</a> version: 8.0.1</p></div><p><b>status</b>: Active</p><p><b>intent</b>: Order</p><p><b>category</b>: <span title="Codes:{http://snomed.info/sct 386053000}">Evaluation procedure (procedure)</span></p><p><b>priority</b>: Routine</p><p><b>code</b>: <span title="Codes:{http://snomed.info/sct 185389009}">Follow-up visit (procedure)</span></p><p><b>subject</b>: <a href="Patient-Example-Fiction.html">Jane Fiction Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH26)</a></p><p><b>occurrence</b>: 2024-05-28</p><p><b>authoredOn</b>: 2024-05-18</p><p><b>requester</b>: <a href="PractitionerRole-PractitionerRole-Physician-PriyaSarkar.html">PractitionerRole Emergency Medicine Physician</a></p></div>
</text>
<status value="active"/>
<intent value="order"/>
<category>
<coding>
<system value="http://snomed.info/sct"/>
<code value="386053000"/>
<display value="Evaluation procedure (procedure)"/>
</coding>
</category>
<priority value="routine"/>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="185389009"/>
<display value="Follow-up visit (procedure)"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/Example-Fiction"/>
</subject>
<occurrenceDateTime value="2024-05-28"/>
<authoredOn value="2024-05-18"/>
<requester>🔗
<reference
value="PractitionerRole/PractitionerRole-Physician-PriyaSarkar"/>
</requester>
</ServiceRequest>
</resource>
<request>
<method value="PUT"/>
<url value="ServiceRequest/JF-PCPFollowUp"/>
</request>
</entry>
<entry>
<fullUrl
value="https://gw.interop.community/pacior4test/open/Location/org-Loc-HomeHealth-Motown"/>
<resource>
<Location>
<id value="org-Loc-HomeHealth-Motown"/>
<meta>
<profile
value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-location|8.0.1"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Location_org-Loc-HomeHealth-Motown"> </a><p class="res-header-id"><b>Generated Narrative: Location org-Loc-HomeHealth-Motown</b></p><a name="org-Loc-HomeHealth-Motown"> </a><a name="hcorg-Loc-HomeHealth-Motown"> </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"/><p style="margin-bottom: 0px">Profile: <a href="http://hl7.org/fhir/us/core/STU8.0.1/StructureDefinition-us-core-location.html">US Core Location Profile</a> version: 8.0.1</p></div><p><b>status</b>: Active</p><p><b>name</b>: Motown Home Health Facility</p><p><b>address</b>: 121 Spruce Dr. Grand Rapids, MI 49503</p><p><b>managingOrganization</b>: <a href="Organization-org-HomeHealth-Motown.html">Organization Motown Home Health Grand Rapids</a></p></div>
</text>
<status value="active"/>
<name value="Motown Home Health Facility"/>
<address>
<text value="121 Spruce Dr. Grand Rapids, MI 49503"/>
<line value="121 Spruce Dr."/>
<city value="Grand Rapids"/>
<state value="MI"/>
<postalCode value="49503"/>
<country value="US"/>
</address>
<managingOrganization>🔗
<reference value="Organization/org-HomeHealth-Motown"/>
</managingOrganization>
</Location>
</resource>
<request>
<method value="PUT"/>
<url value="Location/org-Loc-HomeHealth-Motown"/>
</request>
</entry>
<entry>
<fullUrl
value="https://gw.interop.community/pacior4test/open/Location/org-Loc-ED-Metro-Hospital"/>
<resource>
<Location>
<id value="org-Loc-ED-Metro-Hospital"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Location_org-Loc-ED-Metro-Hospital"> </a><p class="res-header-id"><b>Generated Narrative: Location org-Loc-ED-Metro-Hospital</b></p><a name="org-Loc-ED-Metro-Hospital"> </a><a name="hcorg-Loc-ED-Metro-Hospital"> </a><p><b>status</b>: Active</p><p><b>name</b>: Metro Hospital Emergency Department</p><p><b>telecom</b>: ph: (555) 384-4444</p><p><b>address</b>: 22327 Moross Rd, Detroit, MI 48236</p></div>
</text>
<status value="active"/>
<name value="Metro Hospital Emergency Department"/>
<telecom>
<system value="phone"/>
<value value="(555) 384-4444"/>
</telecom>
<address>
<text value="22327 Moross Rd, Detroit, MI 48236"/>
<line value="22327 Moross Rd, Detroit, MI 48236"/>
<city value="Detroit"/>
<state value="MI"/>
<postalCode value="48236"/>
<country value="US"/>
</address>
</Location>
</resource>
<request>
<method value="PUT"/>
<url value="Location/org-Loc-ED-Metro-Hospital"/>
</request>
</entry>
<entry>
<fullUrl
value="https://gw.interop.community/pacior4test/open/Organization/org-HomeHealth-Motown"/>
<resource>
<Organization>
<id value="org-HomeHealth-Motown"/>
<meta>
<profile
value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization|8.0.1"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_org-HomeHealth-Motown"> </a><p class="res-header-id"><b>Generated Narrative: Organization org-HomeHealth-Motown</b></p><a name="org-HomeHealth-Motown"> </a><a name="hcorg-HomeHealth-Motown"> </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"/><p style="margin-bottom: 0px">Profile: <a href="http://hl7.org/fhir/us/core/STU8.0.1/StructureDefinition-us-core-organization.html">US Core Organization Profile</a> version: 8.0.1</p></div><p><b>active</b>: true</p><p><b>name</b>: Motown Home Health Grand Rapids</p><p><b>telecom</b>: ph: (210) 555-2882</p><p><b>address</b>: 121 Spruce Dr. Grand Rapids, MI 49503</p></div>
</text>
<active value="true"/>
<name value="Motown Home Health Grand Rapids"/>
<telecom>
<system value="phone"/>
<value value="(210) 555-2882"/>
</telecom>
<address>
<text value="121 Spruce Dr. Grand Rapids, MI 49503"/>
<line value="121 Spruce Dr."/>
<city value="Grand Rapids"/>
<state value="MI"/>
<postalCode value="49503"/>
<country value="US"/>
</address>
</Organization>
</resource>
<request>
<method value="PUT"/>
<url value="Organization/org-HomeHealth-Motown"/>
</request>
</entry>
<entry>
<fullUrl
value="https://gw.interop.community/pacior4test/open/Organization/org-ED-Metro-Hospital"/>
<resource>
<Organization>
<id value="org-ED-Metro-Hospital"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_org-ED-Metro-Hospital"> </a><p class="res-header-id"><b>Generated Narrative: Organization org-ED-Metro-Hospital</b></p><a name="org-ED-Metro-Hospital"> </a><a name="hcorg-ED-Metro-Hospital"> </a><p><b>active</b>: true</p><p><b>name</b>: Metro Hospital Emergency Department</p><p><b>telecom</b>: ph: (555) 384-4444</p><p><b>address</b>: 22327 Moross Rd, Detroit, MI 48236</p></div>
</text>
<active value="true"/>
<name value="Metro Hospital Emergency Department"/>
<telecom>
<system value="phone"/>
<value value="(555) 384-4444"/>
</telecom>
<address>
<text value="22327 Moross Rd, Detroit, MI 48236"/>
<line value="22327 Moross Rd, Detroit, MI 48236"/>
<city value="Detroit"/>
<state value="MI"/>
<postalCode value="48236"/>
<country value="US"/>
</address>
</Organization>
</resource>
<request>
<method value="PUT"/>
<url value="Organization/org-ED-Metro-Hospital"/>
</request>
</entry>
<entry>
<fullUrl
value="https://gw.interop.community/pacior4test/open/Practitioner/Practitioner-JudySalas"/>
<resource>
<Practitioner>
<id value="Practitioner-JudySalas"/>
<meta>
<versionId value="4"/>
<lastUpdated value="2024-09-21T14:11:15.000+00:00"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Practitioner_Practitioner-JudySalas"> </a><p class="res-header-id"><b>Generated Narrative: Practitioner Practitioner-JudySalas</b></p><a name="Practitioner-JudySalas"> </a><a name="hcPractitioner-JudySalas"> </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: 4; Last updated: 2024-09-21 14:11:15+0000</p></div><p><b>identifier</b>: <code>http://example.org/fhir/MI-state-license</code>/480410286</p><p><b>active</b>: true</p><p><b>name</b>: Judy Salas</p><p><b>telecom</b>: ph: (555) 944-2454, <a href="mailto:jsalas@MotownHHA.com">jsalas@MotownHHA.com</a></p><p><b>address</b>: 17010 Harper Ave, Detroit, MI 48224</p><p><b>gender</b>: Female</p></div>
</text>
<identifier>
<system value="http://example.org/fhir/MI-state-license"/>
<value value="480410286"/>
</identifier>
<active value="true"/>
<name>
<text value="Judy Salas"/>
<family value="Salas"/>
<given value="Judy"/>
</name>
<telecom>
<system value="phone"/>
<value value="(555) 944-2454"/>
</telecom>
<telecom>
<system value="email"/>
<value value="jsalas@MotownHHA.com"/>
</telecom>
<address>
<text value="17010 Harper Ave, Detroit, MI 48224"/>
<line value="17010 Harper Ave"/>
<city value="Detroit"/>
<state value="MI"/>
<postalCode value="48224"/>
<country value="US"/>
</address>
<gender value="female"/>
</Practitioner>
</resource>
<request>
<method value="PUT"/>
<url value="Practitioner/Practitioner-JudySalas"/>
</request>
</entry>
<entry>
<fullUrl
value="https://gw.interop.community/pacior4test/open/Practitioner/Practitioner-PriyaSarkar"/>
<resource>
<Practitioner>
<id value="Practitioner-PriyaSarkar"/>
<meta>
<versionId value="4"/>
<lastUpdated value="2024-09-21T14:11:15.000+00:00"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Practitioner_Practitioner-PriyaSarkar"> </a><p class="res-header-id"><b>Generated Narrative: Practitioner Practitioner-PriyaSarkar</b></p><a name="Practitioner-PriyaSarkar"> </a><a name="hcPractitioner-PriyaSarkar"> </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: 4; Last updated: 2024-09-21 14:11:15+0000</p></div><p><b>identifier</b>: <a href="http://terminology.hl7.org/6.2.0/NamingSystem-npi.html" title="National Provider Identifier">United States National Provider Identifier</a>/4362436261</p><p><b>active</b>: true</p><p><b>name</b>: Priya Sarkar</p><p><b>telecom</b>: ph: (555) 375-3777, <a href="mailto:psarkar@MetroHospital.com">psarkar@MetroHospital.com</a></p><p><b>address</b>: 22327 Moross Rd, Detroit, MI 48236</p><p><b>gender</b>: Female</p></div>
</text>
<identifier>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="4362436261"/>
</identifier>
<active value="true"/>
<name>
<text value="Priya Sarkar"/>
<family value="Sarkar"/>
<given value="Priya"/>
</name>
<telecom>
<system value="phone"/>
<value value="(555) 375-3777"/>
</telecom>
<telecom>
<system value="email"/>
<value value="psarkar@MetroHospital.com"/>
</telecom>
<address>
<text value="22327 Moross Rd, Detroit, MI 48236"/>
<line value="22327 Moross Rd"/>
<city value="Detroit"/>
<state value="MI"/>
<postalCode value="48236"/>
<country value="US"/>
</address>
<gender value="female"/>
</Practitioner>
</resource>
<request>
<method value="PUT"/>
<url value="Practitioner/Practitioner-PriyaSarkar"/>
</request>
</entry>
<entry>
<fullUrl
value="https://gw.interop.community/pacior4test/open/PractitionerRole/PractitionerRole-Physician-PriyaSarkar"/>
<resource>
<PractitionerRole>
<id value="PractitionerRole-Physician-PriyaSarkar"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="PractitionerRole_PractitionerRole-Physician-PriyaSarkar"> </a><p class="res-header-id"><b>Generated Narrative: PractitionerRole PractitionerRole-Physician-PriyaSarkar</b></p><a name="PractitionerRole-Physician-PriyaSarkar"> </a><a name="hcPractitionerRole-Physician-PriyaSarkar"> </a><p><b>active</b>: true</p><p><b>practitioner</b>: <a href="Practitioner-Practitioner-PriyaSarkar.html">Priya Sarkar</a></p><p><b>organization</b>: <a href="Organization-org-ED-Metro-Hospital.html">Metro Hospital Emergency Department</a></p><p><b>code</b>: <span title="Codes:{http://nucc.org/provider-taxonomy 207P00000X}">Emergency Medicine Physician</span></p><p><b>location</b>: <a href="Location-org-Loc-ED-Metro-Hospital.html">Location Metro Hospital Emergency Department</a></p></div>
</text>
<active value="true"/>
<practitioner>🔗
<reference value="Practitioner/Practitioner-PriyaSarkar"/>
<display value="Priya Sarkar"/>
</practitioner>
<organization>🔗
<reference value="Organization/org-ED-Metro-Hospital"/>
<display value="Metro Hospital Emergency Department"/>
</organization>
<code>
<coding>
<system value="http://nucc.org/provider-taxonomy"/>
<code value="207P00000X"/>
<display value="Emergency Medicine Physician"/>
</coding>
</code>
<location>🔗
<reference value="Location/org-Loc-ED-Metro-Hospital"/>
</location>
</PractitionerRole>
</resource>
<request>
<method value="PUT"/>
<url value="PractitionerRole/PractitionerRole-Physician-PriyaSarkar"/>
</request>
</entry>
<entry>
<fullUrl
value="https://gw.interop.community/pacior4test/open/DocumentReference/JF-DocumentReference"/>
<resource>
<DocumentReference>
<id value="JF-DocumentReference"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-toc/StructureDefinition/TOC-DocumentReference"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="DocumentReference_JF-DocumentReference"> </a><p>Transition of Care DocumentReference for Patient Jane Fiction</p></div>
</text>
<extension
url="http://hl7.org/fhir/us/pacio-toc/StructureDefinition/point-of-contact-extension">
<valueReference>🔗
<reference value="Practitioner/Practitioner-JudySalas"/>
</valueReference>
</extension>
<masterIdentifier>
<system value="http://example.org/MotownHomeHealth/id"/>
<value value="0-87f37989294a408897aacd1fc5d8fd26"/>
</masterIdentifier>
<identifier>
<system value="http://example.org/MotownHomeHealth/id"/>
<value value="0-87f37989294a408897aacd1fc5d8fd26"/>
</identifier>
<status value="current"/>
<docStatus value="final"/>
<type>
<coding>
<system value="http://loinc.org"/>
<code value="18761-7"/>
<display value="Transfer Summary Note"/>
</coding>
</type>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category"/>
<version value="8.0.1"/>
<code value="clinical-note"/>
</coding>
</category>
<subject>🔗
<reference value="Patient/Example-Fiction"/>
</subject>
<date value="2024-05-10T14:25:34.001-05:00"/>
<content>
<attachment>
<contentType value="application/fhir+json"/>
<url
value="https://gw.interop.community/pacior4test/open/Composition/JF-TOCComposition2"/>
<creation value="2024-05-10T14:25:34.001-05:00"/>
</attachment>
</content>
</DocumentReference>
</resource>
<request>
<method value="PUT"/>
<url value="DocumentReference/JF-DocumentReference"/>
</request>
</entry>
</Bundle>
IG © 2024+ HL7 International / Patient Care. Package hl7.fhir.us.pacio-toc#1.0.0 based on FHIR 4.0.1. Generated 2026-09-10
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