// Instance: Progress-Note-Example // InstanceOf: Composition // Description: "John Doe - Composition - Progress Note" // 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-Progress-Note" // * language = #en-US // * identifier.system = "urn:ietf:rfc:3986" // * identifier.value = "1" // * status = #preliminary // * type = http://loinc.org#11506-3 "Provider-unspecified Progress note" // * subject = Reference(Patient/jane-doe) "Jane Doe" // * date = "2016-02-28T09:10:14Z" // * author = Reference(Practitioner/practitioner-1) "Ronald Boone, MD" // * title = "Progress Note" // * confidentiality = #N // * attester.mode = #legal // * attester.time = "2012-01-04T09:10:14Z" // * 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" // * 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 = "Assessment Section" // * section[=].code = http://loinc.org#51848-0 "Assessment (evaluation)" // * section[=].text.status = #generated // * section[=].text.div = "

Obesity.

Uncontrolled brittle Type II diabetic.

Shortness of breath, mild wheezing.

Pressure ulder on left knee.

" // * section[+].title = "Assessment and Plan Section" // * section[=].code = http://loinc.org#51847-2 "Assessment (evaluation) and plan" // * section[=].text.status = #generated // * section[=].text.div = "

Recurrent GI bleed of unknown etiology; hypotension perhaps\n secondary to this but as likely secondary to polypharmacy

Acute on chronic anemia secondary to #1.

Azotemia, acute renal failure with volume loss secondary tom#1.

Hyperkalemia secondary to #3 and on ACE and K+ supplement.

Other chronic diagnoses as noted above, currently stable.

" // * section[+].title = "Chief Complaint Section" // * section[=].code = http://loinc.org#10154-3 "Chief complaint" // * section[=].text.status = #generated // * section[=].text.div = "

Dark Stools

" // * section[+].title = "Instructions Section" // * section[=].code = http://loinc.org#69730-0 "Instructions" // * section[=].text.status = #generated // * section[=].text.div = "

Patient may have low grade fever, mild joint pain and injection area tenderness.

" // * section[+].title = "Interventions Section" // * section[=].code = http://loinc.org#62387-6 "Interventions provided" // * section[=].text.status = #generated // * section[=].text.div = "
Planned InterventionStatusDate
Elevate head of bedactiveSeptember 2, 2016
Oxygen administration by nasal cannulaactiveSeptember 1, 2016
pulse oximetry monitoringactiveSeptember 3, 2016
" // * section[+].title = "Nutrition Section" // * section[=].code = http://loinc.org#61144-2 "Diet and nutrition" // * section[=].text.status = #generated // * section[=].text.div = "
DateNutritional StatusDiet
2005/12/29Well nourishedLow sodium diet, excessive carbohydrate
2010/05/26Slight dehydrationHigh protein, low fibre
" // * section[+].title = "Physical Exam Section" // * section[=].code = http://loinc.org#29545-1 "Physical findings" // * section[=].text.status = #generated // * section[=].text.div = "

HEENT: All normal to examination.

>HEART: RRR, no murmur.

THORAX & LUNGS: Clear without rhonchi or wheeze.

ABDOMEN: Marked distension and tenderness, slightly obese, pos bowelsounds.

BACK: Normal to inspection and palpation, without tenderness; no presacral edema.

EXTREMITIES: Doughy edema bilaterally, chronic stasis changes, no asymmetrical swelling.

" // * section[+].title = "Objective Section" // * section[=].code = http://loinc.org#61149-1 "Objective" // * section[=].text.status = #generated // * section[=].text.div = "

Chest: clear to ausc. No rales, normal breath sounds

Heart: RR, PMI in normal location and no heave or evidence ofcardiomegaly,normal heart sounds, no murm or gallop

" // * section[+].title = "Subjective Section" // * section[=].code = http://loinc.org#61150-9 "Subjective" // * section[=].text.status = #generated // * section[=].text.div = "

Complaints of rectal bleeding, fatigue and a change in bowel patterns.

Has several days of constipation alternating with diarrhea.

" // * section[+].title = "Review of Systems Section" // * section[=].code = http://loinc.org#10187-3 "Review of systems" // * section[=].text.status = #generated // * section[=].text.div = "

Patient denies recent history of fever or malaise. Positive for weakness and\n shortness of breath. Several episodes of abdominal tenderness. No recent headaches. \n Positive for osteoarthritis in hips, knees and hands.

" // * 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/5ml20160401ActivePneumoniaGeneric substitution allowed
" // * section[=].entry = Reference(MedicationStatement/medication-statement) // * 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
Colonoscopy2010/08/16 - 2010/08/16Completed
Recommendation to Exercise2015/10/29Ongoing
" // * section[+].title = "Problem Section" // * section[=].code = http://loinc.org#11450-4 "Problem list" // * section[=].text.status = #generated // * section[=].text.div = "
Problem NameTypeOnset DateAbatement DateStatus
FeverCondition2016-04-012016-04-14Complete
" // * section[=].entry = Reference(Condition/condition-problem) // * 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 = "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)