PACIO Transitions of Care Implementation Guide
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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-ballot 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: Transition of Care Bundle

Document Details

Document Subject

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

Profile: US Core Patient Profileversion: null6.1.0)

Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)


Active:trueMarital Status:unknown
Other Id:Medical Record Number/1032702 (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:

Document Content

List of allergies for Betsy Smith-Johnson

Allergies for Betsy Smith-Johnson

Functional status of Betsy Smith-Johnson

Functional status of Betsy Smith-Johnson

List of medications prescribed for Betsy Smith-Johnson

List of medications prescribed for Betsy Smith-Johnson

Discharge care plan for Betsy Smith-Johnson

Discharge care plan for Betsy Smith-Johnson

List of problem conditions and observations for Betsy Smith-Johnson

List of problem conditions and observations for Betsy Smith-Johnson

Reason for referring Betsy Smith-Johnson

Reason for referring Betsy Smith-Johnson

List of test results for Betsy Smith-Johnson

List of test results for Betsy Smith-Johnson

Additional Resources Included in Document


Entry 2 - fullUrl = http://www.example.org/fhir/Patient/Example-Smith-Johnson-Patient1

Resource Patient:

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

Profile: US Core Patient Profileversion: null6.1.0)

Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)


Active:trueMarital Status:unknown
Other Id:Medical Record Number/1032702 (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:

Entry 3 - fullUrl = http://www.example.org/fhir/Encounter/BSJ-Encounter

Resource Encounter:

status: completed

class: Home Health

type: Evaluation and management of patient at home (procedure)

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

participant


Entry 4 - fullUrl = http://www.example.org/fhir/AllergyIntolerance/BSJ-AllergyACE

Resource AllergyIntolerance:

clinicalStatus: Active

verificationStatus: Confirmed

category: Medication

criticality: High Risk

code: Substance with angiotensin-converting enzyme inhibitor mechanism of action (substance)

patient: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

lastOccurrence: 2011-10

Reactions

-SubstanceManifestation
*captopril 12.5 MG Oral TabletNo display for AllergyIntolerance.reaction.manifestation (concept: Hyperkalemia caused by angiotensin-converting enzyme inhibitor (disorder))

Entry 5 - fullUrl = http://www.example.org/fhir/Condition/BSJ-AnemiaDiagnosis

Resource Condition:

Condition Asserted Date: 2024-04-23 13:15:00-0400

clinicalStatus: Active

verificationStatus: Confirmed

category: Encounter Diagnosis

code: Anemia co-occurrent and due to chronic kidney disease stage 3 (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#10A3D58WH1600)

recordedDate: 2024-04-23 13:15:00-0400

note:

See lab


Entry 6 - fullUrl = http://www.example.org/fhir/Condition/BSJ-ConstipationDiagnosis

Resource Condition:

Condition Asserted Date: 2020-11

clinicalStatus: Active

verificationStatus: Confirmed

category: Encounter Diagnosis

code: Drug-induced constipation (disorder)

bodySite: Colon structure (body structure)

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)


Entry 7 - fullUrl = http://www.example.org/fhir/Condition/BSJ-DepressionDiagnosis

Resource Condition:

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#10A3D58WH1600)


Entry 8 - fullUrl = http://www.example.org/fhir/Condition/BSJ-DiabetesDiagnosis

Resource Condition:

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#10A3D58WH1600)

onset: 2017-06

recordedDate: 2017-06-05


Entry 9 - fullUrl = http://www.example.org/fhir/Condition/BSJ-DressingConcern

Resource Condition:

clinicalStatus: Active

verificationStatus: Confirmed

category: Problem List Item

code: Difficulty performing dressing activity (finding)

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

recordedDate: 2024-04-27 15:40:00-0400

note:

Betsy is frustrated, embarrassed, and worried about not being able to dress herself


Entry 10 - fullUrl = http://www.example.org/fhir/Condition/BSJ-HeartDiseaseDiagnosis

Resource Condition:

Condition Asserted Date: 2019-06

clinicalStatus: Active

verificationStatus: Confirmed

category: Encounter Diagnosis

code: Ischemic heart disease (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#10A3D58WH1600)

recordedDate: 2019-06-08 14:15:00-0400


Entry 11 - fullUrl = http://www.example.org/fhir/Condition/BSJ-HemiparesisDiagnosis

Resource Condition:

Condition Asserted Date: 2024-04-18 13:30:00-0400

clinicalStatus: Active

verificationStatus: Confirmed

category: Encounter Diagnosis

code: Right hemiparesis (disorder)

bodySite: Right upper arm structure (body structure)

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

onset: 2024-04-17 15:40:00-0400

recordedDate: 2024-04-18 13:30:00-0400

note:

Patient began experiencing right sided weakness, primarily in arm and shoulder. There was no facial droop, but patient reports "tingling" in R face / numbness along R brow. Symptoms in face resolved post tPA administration. Strength improved in shoulder, weakness did not fully resolve. Demonstrates R arm weakness and lack of coordination. Fine motor skills significantly degraded and have not improved post tPA.


Entry 12 - fullUrl = http://www.example.org/fhir/Condition/BSJ-HyperlipidemiaDiagnosis

Resource Condition:

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#10A3D58WH1600)


Entry 13 - fullUrl = http://www.example.org/fhir/Condition/BSJ-HypertensionDiagnosis

Resource Condition:

Condition Asserted Date: 2011-09

clinicalStatus: Active

verificationStatus: Confirmed

category: Encounter Diagnosis

code: Hypertensive disorder, systemic arterial (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#10A3D58WH1600)

onset: 2011-08

recordedDate: 2011-09-17


Entry 14 - fullUrl = http://www.example.org/fhir/Condition/BSJ-KidneyDiseaseDiagnosis

Resource Condition:

Condition Asserted Date: 2021-04

clinicalStatus: Active

verificationStatus: Confirmed

category: Encounter Diagnosis

code: Chronic kidney disease stage 3 due to type 2 diabetes mellitus (disorder)

bodySite: Both kidneys (body structure)

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

recordedDate: 2021-04-10 15:00:00-0400


Entry 15 - fullUrl = http://www.example.org/fhir/Condition/BSJ-NauseaAndVomiting

Resource Condition:

Condition Asserted Date: 2024-04-18 16:30:00-0400

clinicalStatus: Active

verificationStatus: Confirmed

category: Encounter Diagnosis

code: Nausea and Vomiting (disorder)

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

onset: 2024-04-18 16:30:00-0400

recordedDate: 2024-04-18 16:30:00-0400

note:

Patient pressed call button for vomiting. She reports she started feeling nauseated about ten minutes ago.


Entry 16 - fullUrl = http://www.example.org/fhir/Condition/BSJ-NeuropathyDiagnosis

Resource Condition:

Condition Asserted Date: 2020-07

clinicalStatus: Active

verificationStatus: Confirmed

category: Encounter Diagnosis

code: Chronic painful neuropathy due to diabetes mellitus (disorder)

bodySite: Both lower legs (body structure)

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)


Entry 17 - fullUrl = http://www.example.org/fhir/Condition/BSJ-StrokeDiagnosis

Resource Condition:

Condition Asserted Date: 2024-04-17 15:40:00-0400

clinicalStatus: Active

verificationStatus: Confirmed

category: Encounter Diagnosis

code: Ischemic Stroke (disorder)

bodySite: Structure of middle cerebral artery M1 segment (body structure), Left

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

onset: 2024-04-17 15:40:00-0400

recordedDate: 2023-12-15 18:40:00-0400

note:

Partial occlusion of MCA. Stroke event witnessed. EMS response / patient arrived within 45 minutes of symptom onset. Verified by CT with contrast. tPA administered within 2 hours of symptom onset.


Entry 18 - fullUrl = http://www.example.org/fhir/Condition/BSJ-UndressingConcern

Resource Condition:

clinicalStatus: Active

verificationStatus: Confirmed

category: Problem List Item

code: Difficulty undressing (finding)

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

recordedDate: 2024-04-27 15:40:00-0400

note:

Betsy is frustrated, embarrassed, and worried about not being able to undress herself


Entry 19 - fullUrl = http://www.example.org/fhir/Condition/OT-ProblemList-Decondition

Resource Condition:

Condition Asserted Date: 2024-04-30 15:40:00-0400

clinicalStatus: Active

verificationStatus: Confirmed

category: Problem List Item

code: Physical deconditioning (finding)

bodySite: Entire lower body (body structure)

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

onset: 2024-04-26 15:40:00-0400

recordedDate: 2024-04-30 15:40:00-0400

evidence

evidence

evidence

note:

The weakness in the patient's lower extremities is secondary to deconditioning. According to the report from Neurology, patient did not have motor or sensory deficits below upper chest. High rehab potential.


Entry 20 - fullUrl = http://www.example.org/fhir/Condition/OT-ProblemList-RightWeak

Resource Condition:

Condition Asserted Date: 2024-04-17 15:40:00-0400

clinicalStatus: Active

verificationStatus: Confirmed

category: Problem List Item

code: Muscle weakness of upper limb (finding)

bodySite: Right upper arm structure (body structure)

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

recordedDate: 2024-04-27 15:40:00-0400

evidence

note:

The weakness and lack of coordination in the patient's right shoulder, arm, and hand are secondary to the stroke. PT/OT from SNF report improvements to rotator cuff strength over last month.


Entry 21 - fullUrl = http://www.example.org/fhir/Observation/BSJ-MDS-Doffing1

Resource Observation:

Event Location: Location Happy Nursing Facility

status: Final

category: Survey, Functional Status, Taking Off Clothes

code: Upper body dressing - functional goal during assessment period [CMS Assessment]

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

effective: 2024-05-16 14:30:00-0400

performer: PractitionerRole Occupational Therapist

value: Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.


Entry 22 - fullUrl = http://www.example.org/fhir/Observation/BSJ-MDS-Donning1

Resource Observation:

Event Location: Location Happy Nursing Facility

status: Final

category: Survey, Functional Status, Putting On Clothes

code: Lower body dressing - functional goal during assessment period [CMS Assessment]

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

effective: 2024-05-16 14:30:00-0400

performer: PractitionerRole Occupational Therapist

value: Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.


Entry 23 - fullUrl = http://www.example.org/fhir/Observation/BSJ-MDS-Mobility-PT1

Resource Observation:

Event Location: Location Happy Nursing Facility

status: Final

category: Survey, Functional Status, Mobility

code: MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

effective: 2024-05-16 14:30:00-0400

performer: PractitionerRole Occupational Therapist

hasMember:


Entry 24 - fullUrl = http://www.example.org/fhir/Observation/BSJ-MDS-ShortWalk1

Resource Observation:

Event Location: Location Happy Nursing Facility

status: Final

category: Survey, Functional Status, Moving Around Within the Home

code: Walk 50 feet with two turns - functional goal during assessment period [CMS Assessment]

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

effective: 2024-05-16 14:30:00-0400

performer: PractitionerRole Occupational Therapist

value: Partial/moderate assistance - helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.


Entry 25 - fullUrl = http://www.example.org/fhir/Observation/BSJ-MDS-SitStand1

Resource Observation:

Event Location: Location Happy Nursing Facility

status: Final

category: Survey, Functional Status, Standing

code: Sit to stand - functional goal during assessment period [CMS Assessment]

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

effective: 2024-05-16 14:30:00-0400

performer: PractitionerRole Occupational Therapist

value: Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.


Entry 26 - fullUrl = http://www.example.org/fhir/Observation/BSJ-MDS-SitUp1

Resource Observation:

Event Location: Location Happy Nursing Facility

status: Final

category: Survey, Functional Status, Lying Down

code: Lying to sitting on side of bed - functional goal during assessment period [CMS Assessment]

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

effective: 2024-05-16 14:30:00-0400

performer: PractitionerRole Occupational Therapist

value: Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently.


Entry 27 - fullUrl = http://www.example.org/fhir/List/BSJ-SMPMedList

Resource List:

Home Medication List

Date: 2024-08-11 Mode: Working List Status: Current Code: Patient generated medication list [Identifier] Episode Pharmacy
Subject: Betsy Smith-Johnson
ItemsDate
atorvastatin 40 MG Oral Tablet2024-08-11
sertraline 25 MG Oral Tablet2024-08-11
furosemide 20 MG Oral Tablet2024-08-11
carvedilol 6.25 MG Oral Tablet2024-08-11
24 HR glipizide 2.5 MG Extended Release Oral Tablet2024-08-11
rosuvastatin calcium 5 MG Oral Tablet2024-08-11
acetaminophen 650 MG Oral Tablet2024-08-11
ferrous sulfate 325 MG (iron 65 MG) Oral Tablet2024-08-11

Entry 28 - fullUrl = http://www.example.org/fhir/MedicationStatement/BSJ-SMPMedStmt1

Resource MedicationStatement:

status: active

status: recorded

subject: Betsy Smith-Johnson

dateAsserted: 2024-08-11

informationSource: Happy Nursing Facility

Dosages

-SequenceText
*1po nightly

Entry 29 - fullUrl = http://www.example.org/fhir/MedicationStatement/BSJ-SMPMedStmt2

Resource MedicationStatement:

status: active

status: recorded

subject: Betsy Smith-Johnson

dateAsserted: 2024-08-11

informationSource: Happy Nursing Facility

Dosages

-SequenceText
*1po nightly

Entry 30 - fullUrl = http://www.example.org/fhir/MedicationStatement/BSJ-SMPMedStmt3

Resource MedicationStatement:

status: active

status: recorded

subject: Betsy Smith-Johnson

dateAsserted: 2024-08-11

informationSource: Happy Nursing Facility

Dosages

-SequenceText
*1po daily

Entry 31 - fullUrl = http://www.example.org/fhir/MedicationStatement/BSJ-SMPMedStmt4

Resource MedicationStatement:

status: active

status: recorded

subject: Betsy Smith-Johnson

dateAsserted: 2024-08-11

informationSource: Happy Nursing Facility

Dosages

-SequenceText
*1po twice daily

Entry 32 - fullUrl = http://www.example.org/fhir/MedicationStatement/BSJ-SMPMedStmt5

Resource MedicationStatement:

status: active

status: recorded

subject: Betsy Smith-Johnson

dateAsserted: 2024-08-11

informationSource: Happy Nursing Facility

Dosages

-SequenceText
*1daily

Entry 33 - fullUrl = http://www.example.org/fhir/MedicationStatement/BSJ-SMPMedStmt6

Resource MedicationStatement:

status: active

status: recorded

subject: Betsy Smith-Johnson

dateAsserted: 2024-08-11

informationSource: Happy Nursing Facility

Dosages

-SequenceText
*1Calcium 500 mg

Entry 34 - fullUrl = http://www.example.org/fhir/MedicationStatement/BSJ-SMPMedStmt7

Resource MedicationStatement:

status: active

status: recorded

subject: Betsy Smith-Johnson

dateAsserted: 2024-08-11

informationSource: Happy Nursing Facility

Dosages

-SequenceText
*1every 6 hours or as needed for pain

Entry 35 - fullUrl = http://www.example.org/fhir/MedicationStatement/BSJ-SMPMedStmt8

Resource MedicationStatement:

status: active

status: recorded

subject: Betsy Smith-Johnson

dateAsserted: 2024-08-11

informationSource: Happy Nursing Facility

Dosages

-SequenceText
*1three times a day before meals

Entry 36 - fullUrl = http://www.example.org/fhir/MedicationRequest/BSJ-SMPMedReq1

Resource MedicationRequest:

status: Active

intent: Order

subject: Betsy Smith-Johnson

authoredOn: 2024-08-11

DosageInstructions

-SequenceText
*1po nightly

Entry 37 - fullUrl = http://www.example.org/fhir/MedicationRequest/BSJ-SMPMedReq2

Resource MedicationRequest:

status: Active

intent: Order

subject: Betsy Smith-Johnson

authoredOn: 2024-08-11

DosageInstructions

-SequenceText
*1po nightly

Entry 38 - fullUrl = http://www.example.org/fhir/MedicationRequest/BSJ-SMPMedReq3

Resource MedicationRequest:

status: Active

intent: Order

subject: Betsy Smith-Johnson

authoredOn: 2024-08-11

DosageInstructions

-SequenceText
*1po daily

Entry 39 - fullUrl = http://www.example.org/fhir/MedicationRequest/BSJ-SMPMedReq4

Resource MedicationRequest:

status: Active

intent: Order

subject: Betsy Smith-Johnson

authoredOn: 2024-08-11

DosageInstructions

-SequenceText
*1po twice daily

Entry 40 - fullUrl = http://www.example.org/fhir/MedicationRequest/BSJ-SMPMedReq5

Resource MedicationRequest:

status: Active

intent: Order

subject: Betsy Smith-Johnson

authoredOn: 2024-08-11

DosageInstructions

-SequenceText
*1daily

Entry 41 - fullUrl = http://www.example.org/fhir/MedicationRequest/BSJ-SMPMedReq6

Resource MedicationRequest:

status: Active

intent: Order

subject: Betsy Smith-Johnson

authoredOn: 2024-08-11

DosageInstructions

-SequenceText
*1Calcium 500 mg

Entry 42 - fullUrl = http://www.example.org/fhir/MedicationRequest/BSJ-SMPMedReq7

Resource MedicationRequest:

status: Active

intent: Order

subject: Betsy Smith-Johnson

authoredOn: 2024-08-11

DosageInstructions

-SequenceText
*1every 6 hours or as needed for pain

Entry 43 - fullUrl = http://www.example.org/fhir/MedicationRequest/BSJ-SMPMedReq8

Resource MedicationRequest:

status: Active

intent: Order

subject: Betsy Smith-Johnson

authoredOn: 2024-08-11

DosageInstructions

-SequenceText
*1three times a day before meals

Entry 44 - fullUrl = http://www.example.org/fhir/CarePlan/BSJ-SNFDischargeCarePlan

Resource CarePlan:

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#10A3D58WH1600)

activity

activity

activity

activity

activity

activity

activity

activity

activity


Entry 45 - fullUrl = http://www.example.org/fhir/ServiceRequest/BSJ-PCPFollowUp

Resource ServiceRequest:

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#10A3D58WH1600)

occurrence: 2024-05-28

authoredOn: 2024-05-18

requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician


Entry 46 - fullUrl = http://www.example.org/fhir/ServiceRequest/BSJ-SNFDischargeCallOrder

Resource ServiceRequest:

status: Active

intent: Order

category: Evaluation procedure (procedure)

priority: Routine

code: No display for ServiceRequest.code (concept: Informing doctor (procedure))

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

occurrence: 2024-05-18 --> (ongoing)

authoredOn: 2024-05-18

requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician


Entry 47 - fullUrl = http://www.example.org/fhir/ServiceRequest/BSJ-SNFDischargeCallOTRefer

Resource ServiceRequest:

status: Active

intent: Order

category: Evaluation procedure (procedure)

priority: Routine

code: No display for ServiceRequest.code (concept: Occupational therapy assessment (procedure))

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

occurrence: 2024-05-18 --> (ongoing)

authoredOn: 2024-05-18

requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician


Entry 48 - fullUrl = http://www.example.org/fhir/ServiceRequest/BSJ-SNFDischargeCallSLPRefer

Resource ServiceRequest:

status: Active

intent: Order

category: Evaluation procedure (procedure)

priority: Routine

code: No display for ServiceRequest.code (concept: Speech therapy assessment (procedure))

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

occurrence: 2024-05-18 --> (ongoing)

authoredOn: 2024-05-18

requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician


Entry 49 - fullUrl = http://www.example.org/fhir/ServiceRequest/BSJ-SNFDischargeDietProtein

Resource ServiceRequest:

status: Active

intent: Order

category: Evaluation procedure (procedure)

priority: Routine

code: No display for ServiceRequest.code (concept: Decreased protein and/or protein derivative diet (regime/therapy))

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

occurrence: 2024-05-18 --> (ongoing)

authoredOn: 2024-05-18

requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician


Entry 50 - fullUrl = http://www.example.org/fhir/ServiceRequest/BSJ-SNFDischargeDietSalt

Resource ServiceRequest:

status: Active

intent: Order

category: Evaluation procedure (procedure)

priority: Routine

code: No display for ServiceRequest.code (concept: Decreased sodium diet (regime/therapy))

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

occurrence: 2024-05-18 --> (ongoing)

authoredOn: 2024-05-18

requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician


Entry 51 - fullUrl = http://www.example.org/fhir/ServiceRequest/BSJ-SNFDischargeLabOrderBMP

Resource ServiceRequest:

status: Active

intent: Order

category: Laboratory procedure

priority: Routine

code: No display for ServiceRequest.code (concept: Blood chemistry (procedure))

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

occurrence: 2024-05-28

authoredOn: 2024-05-18

requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician


Entry 52 - fullUrl = http://www.example.org/fhir/ServiceRequest/BSJ-SNFDischargeLabOrderCBC

Resource ServiceRequest:

status: Active

intent: Order

category: Laboratory procedure

priority: Routine

code: No display for ServiceRequest.code (concept: Complete blood count without differential (procedure))

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

occurrence: 2024-05-28

authoredOn: 2024-05-18

requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician


Entry 53 - fullUrl = http://www.example.org/fhir/ServiceRequest/BSJ-SNFDischargePTRefer

Resource ServiceRequest:

status: Active

intent: Order

category: Evaluation procedure (procedure)

priority: Routine

code: No display for ServiceRequest.code (concept: Physical therapy assessment (procedure))

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

occurrence: 2024-05-18 --> (ongoing)

authoredOn: 2024-05-18

requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician


Entry 54 - fullUrl = http://www.example.org/fhir/Location/org-Loc-Neuro-Care-Inc

Resource Location:

status: Active

name: Neuro Care Inc.

address: 177 Branching Tree Blvd, Grand Rapids, MI 49509


Entry 55 - fullUrl = http://www.example.org/fhir/Location/org-Loc-PC-Primary-Care-Michigan

Resource Location:

status: Active

name: Michigan Primary Health Care Associates

address: 123 Spruce Dr. Grand Rapids, MI 49503


Entry 56 - fullUrl = http://www.example.org/fhir/Location/org-Loc-SNF-Happy-Nursing-Facility

Resource Location:

status: Active

name: Happy Nursing Facility

address: 8100 Pinebrook Dr, Grand Rapids, MI 49504


Entry 57 - fullUrl = http://www.example.org/fhir/Organization/org-Neuro-Care-Inc

Resource Organization:

active: true

name: Neuro Care Inc.

Contacts

-TelecomAddress
*ph: (210) 555 5555177 Branching Tree Blvd, Grand Rapids, MI 49509

Entry 58 - fullUrl = http://www.example.org/fhir/Organization/org-PC-Primary-Care-Michigan

Resource Organization:

active: true

name: Michigan Primary Health Care Associates

Contacts

-TelecomAddress
*ph: (616) 555-1212123 Spruce Dr. Grand Rapids, MI 49503

Entry 59 - fullUrl = http://www.example.org/fhir/Organization/org-SNF-Happy-Nursing-Facility

Resource Organization:

active: true

name: Happy Nursing Facility

Contacts

-TelecomAddress
*ph: (210) 555 18718100 Pinebrook Dr, Grand Rapids, MI 49504

Entry 60 - fullUrl = http://www.example.org/fhir/Practitioner/Example-AnitaChu

Resource Practitioner:

identifier: United States National Provider Identifier/8134258523

active: true

name: Anita Chu

telecom: ph: (616) 555-1212

gender: Female

address: 123 Spruce Dr. Grand Rapids, MI 49503


Entry 61 - fullUrl = http://www.example.org/fhir/Practitioner/Example-GeraldPark

Resource Practitioner:

identifier: United States National Provider Identifier/8554084011

active: true

name: Gerald Park

telecom: ph: (555) 566 3494

gender: Male

address: 8100 Pinebrook Dr, Grand Rapids, MI 49504


Entry 62 - fullUrl = http://www.example.org/fhir/Practitioner/Example-JenCadbury

Resource Practitioner:

identifier: United States National Provider Identifier/9635749481

active: true

name: Jen Cadbury

telecom: ph: (210) 555 1871

gender: Female

address: 8100 Pinebrook Dr, Grand Rapids, MI 49504


Entry 63 - fullUrl = http://www.example.org/fhir/Practitioner/Example-NuraMekel

Resource Practitioner:

identifier: United States National Provider Identifier/8224780964

active: true

name: Nura Mekel

telecom: ph: (210) 555 5555

gender: Female

address: 177 Branching Tree Blvd, Grand Rapids, MI 49509


Entry 64 - fullUrl = http://www.example.org/fhir/PractitionerRole/Role-IMMD-AnitaChu

Resource PractitionerRole:

active: true

practitioner: Dr. Anita Chu

organization: Michigan Primary Health Care Associates

code: Internal Medicine Physician

location: Location Michigan Primary Health Care Associates


Entry 65 - fullUrl = http://www.example.org/fhir/PractitionerRole/Role-Neuro-NuraMekel

Resource PractitionerRole:

active: true

practitioner: Nura Mekel

organization: Neuro Care Inc.

code: Neurology Physician

location: Location Neuro Care Inc.


Entry 66 - fullUrl = http://www.example.org/fhir/PractitionerRole/Role-OT-JenCadbury

Resource PractitionerRole:

active: true

practitioner: Jen Cadbury

organization: Happy Nursing Facility

code: Occupational Therapist

location: Location Happy Nursing Facility


Entry 67 - fullUrl = http://www.example.org/fhir/PractitionerRole/Role-SNFDoc-GeraldPark

Resource PractitionerRole:

active: true

practitioner: Gerald Park

organization: Happy Nursing Facility

code: Geriatric Medicine (Family Medicine) Physician

location: Location Happy Nursing Facility