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
Document Details
Profile: Transition of Care Bundle
Final Document at 2024-05-10 08:49:58-0400 by Practitioner Jen Cadbury for Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH16)
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#1AA3D58WH16)
| Active: | true | Marital Status: | unknown | ||
| Other Id: | Medical Record Number/1032702 (use: usual, ) | ||||
| Contact Detail |
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| Language: | English (preferred) | ||||
| son: |
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| daughter: |
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| US Core Race Extension: |
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Document Content
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 Profile version: 8.0.1
Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1AA3D58WH16)
Active: true Marital 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:
- ombCategory: Race & Ethnicity - CDC: 2106-3 (White)
- text: White
Entry 3 - fullUrl = http://www.example.org/fhir/Encounter/BSJ-Encounter
Resource Encounter:
Profile: US Core Encounter Profile version: 8.0.1
status: completed
class: Home Health
type: Evaluation and management of patient at home (procedure)
participant
Locations
Location Location Motown Home Health Facility
Entry 4 - fullUrl = http://www.example.org/fhir/AllergyIntolerance/BSJ-AllergyACE
Resource AllergyIntolerance:
Profile: US Core AllergyIntolerance Profile version: 8.0.1
clinicalStatus: Active
verificationStatus: Confirmed
category: Medication
criticality: High Risk
code: Substance with angiotensin-converting enzyme inhibitor mechanism of action (substance)
lastOccurrence: 2011-10
Reactions
Substance Manifestation captopril 12.5 MG Oral Tablet No display for AllergyIntolerance.reaction.manifestation (concept: Hyperkalemia caused by angiotensin-converting enzyme inhibitor (disorder))
Entry 5 - fullUrl = http://www.example.org/fhir/Condition/BSJ-DressingConcern
Resource Condition:
Profile: US Core Condition Problems and Health Concerns Profile version: 8.0.1
clinicalStatus: Active
verificationStatus: Confirmed
category: Problem List Item
code: Difficulty performing dressing activity (finding)
recordedDate: 2024-04-27 15:40:00-0400
note:
Betsy is frustrated, embarrassed, and worried about not being able to dress herself
Entry 6 - fullUrl = http://www.example.org/fhir/Condition/BSJ-HeartDiseaseDiagnosis
Resource Condition:
Profile: US Core Condition Encounter Diagnosis Profile version: 8.0.1
Condition Asserted Date: 2019-06
clinicalStatus: Active
verificationStatus: Confirmed
category: Encounter Diagnosis
code: Ischemic heart disease (disorder)
bodySite: Structure of cardiovascular system (body structure)
recordedDate: 2019-06-08 14:15:00-0400
Entry 7 - fullUrl = http://www.example.org/fhir/Condition/BSJ-HemiparesisDiagnosis
Resource Condition:
Profile: US Core Condition Encounter Diagnosis Profile version: 8.0.1
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)
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 8 - fullUrl = http://www.example.org/fhir/Condition/BSJ-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)
Entry 9 - fullUrl = http://www.example.org/fhir/Condition/BSJ-HypertensionDiagnosis
Resource Condition:
Profile: US Core Condition Encounter Diagnosis Profile version: 8.0.1
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)
onset: 2011-08
recordedDate: 2011-09-17
Entry 10 - fullUrl = http://www.example.org/fhir/Condition/BSJ-StrokeDiagnosis
Resource Condition:
Profile: US Core Condition Encounter Diagnosis Profile version: 8.0.1
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
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 11 - fullUrl = http://www.example.org/fhir/Condition/OT-ProblemList-RightWeak
Resource Condition:
Profile: US Core Condition Problems and Health Concerns Profile version: 8.0.1
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)
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 12 - fullUrl = http://www.example.org/fhir/Immunization/BSJ-Immunization-PCV20
Resource Immunization:
Profile: US Core Immunization Profile version: 8.0.1
status: Completed
vaccineCode: pneumococcal conjugate vaccine, 13 valent
lotNumber: AAJN88P
patient: Betsy Smith-Johnson
occurrence: 2025-11-19 15:00:00-0800
primarySource: false
location: Home Health - Motown
Performers
Actor Dr. Gerald Park
Entry 13 - fullUrl = http://www.example.org/fhir/Immunization/BSJ-Immunization-Fluzone
Resource Immunization:
Profile: US Core Immunization Profile version: 8.0.1
status: Completed
vaccineCode: Influenza, high-dose, quadrivalent, PF
lotNumber: AAJN55Q
patient: Betsy Smith-Johnson
occurrence: 2025-11-19 15:00:00-0800
primarySource: false
location: Home Health - Motown
Performers
Actor Dr. Gerald Park
Entry 14 - 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-JohnsonSource:
Items Date atorvastatin 40 MG Oral Tablet 2024-08-11 losartan potassium 25 MG Oral Tablet 2024-08-11 clopidogrel 75 MG Oral Tablet 2024-08-11
Entry 15 - fullUrl = http://www.example.org/fhir/MedicationStatement/BSJ-SMPMedStmt1
Resource MedicationStatement:
status: active
status: recorded
subject: Betsy Smith-Johnson
dateAsserted: 2024-08-11
informationSource: Dr. Gerald Park
Dosages
Sequence Text 1 po nightly
Entry 16 - fullUrl = http://www.example.org/fhir/MedicationStatement/BSJ-SMPMedStmt4
Resource MedicationStatement:
status: active
status: recorded
subject: Betsy Smith-Johnson
dateAsserted: 2024-08-11
informationSource: Dr. Gerald Park
Dosages
Sequence Text 1 po once daily
Entry 17 - fullUrl = http://www.example.org/fhir/MedicationStatement/BSJ-SMPMedStmt9
Resource MedicationStatement:
status: active
status: recorded
subject: Betsy Smith-Johnson
dateAsserted: 2024-08-11
informationSource: Dr. Gerald Park
Dosages
Sequence Text 1 po nightly
Entry 18 - fullUrl = http://www.example.org/fhir/MedicationRequest/BSJ-SMPMedReq1
Resource MedicationRequest:
Profile: US Core MedicationRequest Profile
status: Active
intent: Order
subject: Betsy Smith-Johnson
authoredOn: 2024-08-11
requester: Dr. Jen Cadbury
DosageInstructions
Sequence Text 1 po nightly
Entry 19 - fullUrl = http://www.example.org/fhir/MedicationRequest/BSJ-SMPMedReq4
Resource MedicationRequest:
Profile: US Core MedicationRequest Profile
status: Active
intent: Order
subject: Betsy Smith-Johnson
authoredOn: 2024-08-11
requester: Dr. Jen Cadbury
DosageInstructions
Sequence Text 1 po once daily
Entry 20 - fullUrl = http://www.example.org/fhir/MedicationRequest/BSJ-SMPMedReq9
Resource MedicationRequest:
Profile: US Core MedicationRequest Profile
status: Active
intent: Order
subject: Betsy Smith-Johnson
authoredOn: 2024-08-11
requester: Dr. Jen Cadbury
DosageInstructions
Sequence Text 1 po nightly
Entry 21 - fullUrl = http://www.example.org/fhir/CarePlan/BSJ-SNFDischargeCarePlan
Resource CarePlan:
Profile: US Core CarePlan Profile version: 8.0.1
status: Active
intent: Plan
category: Assessment and Plan of Treatment
activity
activity
activity
activity
activity
activity
activity
activity
Entry 22 - fullUrl = http://www.example.org/fhir/ServiceRequest/BSJ-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))
occurrence: 2024-05-28
authoredOn: 2024-05-18
requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician
Entry 23 - fullUrl = http://www.example.org/fhir/ServiceRequest/BSJ-SNFDischargeCallOrder
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: Informing doctor (procedure))
occurrence: 2024-05-18 --> (ongoing)
authoredOn: 2024-05-18
requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician
Entry 24 - fullUrl = http://www.example.org/fhir/ServiceRequest/BSJ-SNFDischargeCallOTRefer
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: Occupational therapy assessment (procedure))
occurrence: 2024-05-18 --> (ongoing)
authoredOn: 2024-05-18
requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician
Entry 25 - fullUrl = http://www.example.org/fhir/ServiceRequest/BSJ-SNFDischargeCallSLPRefer
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: Speech therapy assessment (procedure))
occurrence: 2024-05-18 --> (ongoing)
authoredOn: 2024-05-18
requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician
Entry 26 - fullUrl = http://www.example.org/fhir/ServiceRequest/BSJ-SNFDischargeDietSalt
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: Decreased fat and oil diet (regime/therapy))
occurrence: 2024-05-18 --> (ongoing)
authoredOn: 2024-05-18
requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician
Entry 27 - fullUrl = http://www.example.org/fhir/ServiceRequest/BSJ-SNFDischargeLabOrderBMP
Resource ServiceRequest:
Profile: US Core ServiceRequest Profile version: 8.0.1
status: Active
intent: Order
category: Laboratory procedure
priority: Routine
code: No display for ServiceRequest.code (concept: Blood chemistry (procedure))
occurrence: 2024-05-28
authoredOn: 2024-05-18
requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician
Entry 28 - fullUrl = http://www.example.org/fhir/ServiceRequest/BSJ-SNFDischargeLabOrderCBC
Resource ServiceRequest:
Profile: US Core ServiceRequest Profile version: 8.0.1
status: Active
intent: Order
category: Laboratory procedure
priority: Routine
code: No display for ServiceRequest.code (concept: Complete blood count without differential (procedure))
occurrence: 2024-05-28
authoredOn: 2024-05-18
requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician
Entry 29 - fullUrl = http://www.example.org/fhir/ServiceRequest/BSJ-SNFDischargePTRefer
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: Physical therapy assessment (procedure))
occurrence: 2024-05-18 --> (ongoing)
authoredOn: 2024-05-18
requester: PractitionerRole Geriatric Medicine (Family Medicine) Physician
Entry 30 - fullUrl = http://www.example.org/fhir/Location/org-Loc-Neuro-Care-Inc
Resource Location:
Profile: US Core Location Profile version: 8.0.1
status: Active
name: Neuro Care Inc.
address: 177 Branching Tree Blvd, Grand Rapids, MI 49509
Entry 31 - fullUrl = http://www.example.org/fhir/Location/org-Loc-PC-Primary-Care-Michigan
Resource Location:
Profile: US Core Location Profile version: 8.0.1
status: Active
name: Michigan Primary Health Care Associates
address: 123 Spruce Dr. Grand Rapids, MI 49503
Entry 32 - fullUrl = http://www.example.org/fhir/Location/org-Loc-SNF-Happy-Nursing-Facility
Resource Location:
Profile: US Core Location Profile version: 8.0.1
status: Active
name: Happy Nursing Facility
address: 8100 Pinebrook Dr, Grand Rapids, MI 49504
Entry 33 - fullUrl = http://www.example.org/fhir/Location/org-Loc-HomeHealth-Motown
Resource Location:
Profile: US Core Location Profile version: 8.0.1
status: Active
name: Motown Home Health Facility
address: 121 Spruce Dr. Grand Rapids, MI 49503
managingOrganization: Organization Motown Home Health Grand Rapids
Entry 34 - fullUrl = http://www.example.org/fhir/Organization/org-Neuro-Care-Inc
Resource Organization:
Profile: US Core Organization Profile version: 8.0.1
active: true
name: Neuro Care Inc.
Contacts
Telecom Address ph: (210) 555 5555 177 Branching Tree Blvd, Grand Rapids, MI 49509
Entry 35 - fullUrl = http://www.example.org/fhir/Organization/org-PC-Primary-Care-Michigan
Resource Organization:
Profile: US Core Organization Profile version: 8.0.1
active: true
name: Michigan Primary Health Care Associates
Contacts
Telecom Address ph: (616) 555-1212 123 Spruce Dr. Grand Rapids, MI 49503
Entry 36 - fullUrl = http://www.example.org/fhir/Organization/org-SNF-Happy-Nursing-Facility
Resource Organization:
Profile: US Core Organization Profile version: 8.0.1
active: true
name: Happy Nursing Facility
Contacts
Telecom Address ph: (210) 555 1871 8100 Pinebrook Dr, Grand Rapids, MI 49504
Entry 37 - 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 38 - fullUrl = http://www.example.org/fhir/Practitioner/Example-AnitaChu
Resource Practitioner:
Profile: US Core Practitioner Profile version: 8.0.1
identifier: NPI/8134258523
active: true
name: Anita Chu
telecom: ph: (616) 555-1212
gender: Female
address: 123 Spruce Dr. Grand Rapids, MI 49503
Entry 39 - fullUrl = http://www.example.org/fhir/Practitioner/Example-GeraldPark
Resource Practitioner:
Profile: US Core Practitioner Profile version: 8.0.1
identifier: NPI/8554084011
active: true
name: Gerald Park
telecom: ph: (555) 566 3494
gender: Male
address: 8100 Pinebrook Dr, Grand Rapids, MI 49504
Entry 40 - fullUrl = http://www.example.org/fhir/Practitioner/Example-JenCadbury
Resource Practitioner:
Profile: US Core Practitioner Profile version: 8.0.1
identifier: NPI/9635749481
active: true
name: Jen Cadbury
telecom: ph: (210) 555 1871
gender: Female
address: 8100 Pinebrook Dr, Grand Rapids, MI 49504
Entry 41 - fullUrl = http://www.example.org/fhir/Practitioner/Example-NuraMekel
Resource Practitioner:
Profile: US Core Practitioner Profile version: 8.0.1
identifier: NPI/8224780964
active: true
name: Nura Mekel
telecom: ph: (210) 555 5555
gender: Female
address: 177 Branching Tree Blvd, Grand Rapids, MI 49509
Entry 42 - fullUrl = http://www.example.org/fhir/PractitionerRole/Role-IMMD-AnitaChu
Resource PractitionerRole:
Profile: US Core PractitionerRole Profile version: 8.0.1
active: true
practitioner: Dr. Anita Chu
organization: Michigan Primary Health Care Associates
code: Internal Medicine Physician
Entry 43 - fullUrl = http://www.example.org/fhir/PractitionerRole/Role-Neuro-NuraMekel
Resource PractitionerRole:
Profile: US Core PractitionerRole Profile version: 8.0.1
active: true
practitioner: Nura Mekel
organization: Neuro Care Inc.
code: Neurology Physician
location: Location Neuro Care Inc.
Entry 44 - fullUrl = http://www.example.org/fhir/PractitionerRole/Role-OT-JenCadbury
Resource PractitionerRole:
Profile: US Core PractitionerRole Profile version: 8.0.1
active: true
practitioner: Jen Cadbury
organization: Happy Nursing Facility
code: Occupational Therapist
location: Location Happy Nursing Facility
Entry 45 - fullUrl = http://www.example.org/fhir/PractitionerRole/Role-SNFDoc-GeraldPark
Resource PractitionerRole:
Profile: US Core PractitionerRole Profile version: 8.0.1
active: true
practitioner: Gerald Park
organization: Happy Nursing Facility
code: Geriatric Medicine (Family Medicine) Physician
location: Location Happy Nursing Facility
IG © 2024+ HL7 International / Patient Care. Package hl7.fhir.us.pacio-toc#1.0.0 based on FHIR 4.0.1. Generated 2026-04-25
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