// Instance: ContinuityCareDocument1 // InstanceOf: Composition // Description: "John Doe - Composition - Continuity of Care Document" // Usage: #example // * meta.versionId = "1" // * meta.lastUpdated = "2018-10-04T19:42:52.061-04:00" // * meta.profile = "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Continuity-of-Care-Document" // * language = #en-US // * identifier.system = "urn:ietf:rfc:3986" // * identifier.value = "urn:uuid:7e63fe21-7285-46c6-b72f-e58a61341195" // * status = #preliminary // * type = http://loinc.org#34133-9 "Summary of episode note" // * subject = Reference(Patient/john-doe) "John Doe" // * date = "2016-02-28T09:10:14Z" // * author = Reference(Practitioner/practitioner-1) "Ronald Boone, MD" // * title = "Continuity of Care Document" // * confidentiality = #N // * attester.mode = #legal // * attester.time = "2016-06-15T09:10:14Z" // * attester.party = Reference(Practitioner/practitioner-1) "Ronald Boone, MD" // * custodian = Reference(Organization/organization-1) "Community Health and Hospitals" // * event.code = http://hl7.org/fhir/v3/ActClass#PCPR "Care Provision" // * event.period.start = "2016-06-15" // * event.period.end = "2016-08-20" // * section[0].title = "Allergies and Intolerances Section" // * section[=].code = http://loinc.org#48765-2 "Allergies and adverse reactions" // * section[=].text.status = #generated // * section[=].text.div = "
SubstanceOverall SeverityReactionReaction SeverityStatus
Cashew NutSevereAnaphylactic reactionMildActive
" // * section[=].mode = #snapshot // * section[=].orderedBy = http://hl7.org/fhir/list-order#event-date "Sorted by Event Date" // * section[=].entry = Reference(AllergyIntolerance/allergy-intolerance) // * section[+].title = "Medication Section" // * section[=].code = http://loinc.org#10160-0 "History of Medication Use" // * section[=].text.status = #generated // * section[=].text.div = "
MedicationDirectionsStart DateStatusIndicationsFill Instructions
AmoxicillinAmoxicillin Powder, for Suspension 250mg/5ml2016/02/28ActivePneumoniaGeneric substitution allowed
" // * section[=].entry = Reference(MedicationStatement/medication-statement) // * section[+].title = "Problem Section" // * section[=].code = http://loinc.org#11450-4 "Problem list" // * section[=].text.status = #generated // * section[=].text.div = "
Problem NameTypeOnset DateAbatement DateStatus
FeverCondition2016/02/282016/03/01Complete
" // * section[=].entry = Reference(Condition/condition-problem) // * section[+].title = "Procedures Section" // * section[=].code = http://loinc.org#47519-4 "History of procedures" // * section[=].text.status = #generated // * section[=].text.div = "
Procedure NameBody SitePerformerDate PerformedReason
Appendectomy (Procedure)AbdomenDr. Adam Everyman2016/06/15Generalized abdominal pain 24 hours. Localized in RIF with rebound and guarding
" // * section[=].entry = Reference(Procedure/procedure-rehab) // * section[+].title = "Results Section" // * section[=].code = http://loinc.org#30954-2 "Relevant diagnostic tests and laboratory data" // * section[=].text.status = #generated // * section[=].text.div = "
Result TypeQuantity ValueDateStatus
Glucose [Moles/volume] in Blood6.3 mmol/l2016/06/15Final
" // * section[=].entry = Reference(Observation/observation-lab-urine) // * section[+].title = "Advance Directives Section" // * section[=].code = http://loinc.org#42348-3 "Advance directives" // * section[=].text.status = #generated // * section[=].text.div = "
NameApplies Period
Resuscitation2010/01/01 - 2025/01/01
" // * section[+].title = "Encounters Section" // * section[=].code = http://loinc.org#46240-8 "Encounters" // * section[=].text.status = #generated // * section[=].text.div = "
EncounterPerformerLocationDate
Checkup ExaminationDr. S. SteeneCommunity Urgent Care Center2016/04/18
" // * section[+].title = "Family History Section" // * section[=].code = http://loinc.org#10157-6 "History of family member diseases" // * section[=].text.status = #generated // * section[=].text.div = "
RelationshipDiagnosisAge at Onset
FatherMyocardial Infarction(cause of Death)57
FatherDiabetes40
" // * section[+].title = "Functional Status Section" // * section[=].code = http://loinc.org#47420-5 "Functional status assessment" // * section[=].text.status = #generated // * section[=].text.div = "
Functional or Cognitive FindingObservationObservation DateCondition Status
Ambulation (Dependent to IndependentIndependently able2016/06/15Active
Finding of Functional Performance and ActivityDyspnea2016/06/15Active
Cognitive Function FindingMemory Impairment2010/04/17Active
" // * section[+].title = "Immunizations Section" // * section[=].code = http://loinc.org#11369-6 "History of immunization" // * section[=].text.status = #generated // * section[=].text.div = "
VaccineDateStatus
Fluvax (Influenza)2014/05/29Completed
" // * section[=].entry = Reference(Immunization/immunization) // * section[+].title = "Nutrition Section" // * section[=].code = http://loinc.org#61144-2 "Diet and nutrition" // * section[=].text.status = #generated // * section[=].text.div = "
DateNutritional StatusDiet
2016/06/15Well nourishedLow sodium diet, excessive carbohydrate
2016/06/15Slight dehydrationHigh protein, low fibre
" // * section[+].title = "Mental Status Section" // * section[=].code = http://loinc.org#10190-7 "Mental status" // * section[=].text.status = #generated // * section[=].text.div = "
DateMental StatusSupport System
2016/06/15GoodNot required
2012/04/29DimentiaDaily Home Care
" // * section[+].title = "Social History Section" // * section[=].code = http://loinc.org#29762-2 "Social history" // * section[=].text.status = #generated // * section[=].text.div = "
Social History ElementDescriptionEffective Dates
Smoking1 pack tobacco per day2010/01/01 - 2016/06/15
" // * section[=].entry = Reference(Observation/observation-smoker) // * section[+].title = "Plan of Treatment Section" // * section[=].code = http://loinc.org#18776-5 "Plan of treatment" // * section[=].text.status = #generated // * section[=].text.div = "
Planned ActivityPeriodStatus
Colonoscopy2016/06/15 - 2015/06/15Completed
Recommendation to Exercise2016/06/15Ongoing
" // * section[+].title = "Payers Section" // * section[=].code = http://loinc.org#48768-6 "Payers" // * section[=].text.status = #generated // * section[=].text.div = "
Payer NamePolicy IDPolicy Holder
United Healthcare12341Self
Cigna53123Spouse
" // * section[+].title = "Medical Equipment Section" // * section[=].code = http://loinc.org#46264-8 "Medical equipment" // * section[=].text.status = #generated // * section[=].text.div = "
Supply/DeviceDate Supplied
Automatic Implantable cardioverter/defbrillator2015/05/29
Wheelchair2016/06/15
" // * section[+].title = "Vital Signs Section" // * section[=].code = http://loinc.org#8716-3 "Vital signs" // * section[=].text.status = #generated // * section[=].text.div = "
Vital SignDateValue
Temperature2016/06/1539 Degrees Celcius
" // * section[=].entry = Reference(Observation/observation-vitals-temp)