// Instance: Transfer-Summary-Example
// InstanceOf: Composition
// Description: "John Doe - Composition - Transfer Summary"
// Usage: #example
// * meta.versionId = "2"
// * meta.lastUpdated = "2019-01-25T16:39:56.810-05:00"
// * meta.profile = "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Transfer-Summary"
// * language = #en-US
// * extension[0].url = "https://trifolia-fhir.lantanagroup.com/stu3/StructureDefinition/github-branch"
// * extension[=].valueString = "master"
// * extension[+].url = "https://trifolia-fhir.lantanagroup.com/stu3/StructureDefinition/github-path"
// * extension[=].valueString = "HL7/ccda-on-fhir/source/resources/composition/CCDA-on-FHIR-Transfer-Summary-Example.xml"
// * identifier.system = "urn:ietf:rfc:3986"
// * identifier.value = "1"
// * status = #preliminary
// * type = http://loinc.org#18761-7 "Provider-unspecified Transfer summary"
// * subject = Reference(Patient/john-doe) "John Doe"
// * date = "2016-06-15T09:10:14Z"
// * author = Reference(Practitioner/practitioner-1) "Ronald Boone, MD"
// * title = "Transfer Summary"
// * confidentiality = #N
// * custodian = Reference(Organization/organization-1) "Acme Labs"
// * event.code = http://snomed.info/sct#73761001 "Colonoscopy"
// * event.period.start = "2016-06-15"
// * event.period.end = "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 = "
| Substance | Overall Severity | Reaction | Reaction Severity | Status |
| Cashew Nut | Severe | Anaphylactic reaction | Mild | Active |
"
// * 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 = "Advance Directives Section"
// * section[=].code = http://loinc.org#42348-3 "Advance directives"
// * section[=].text.status = #generated
// * section[=].text.div = "| Name | Applies Period |
| Resuscitation | 2015/01/01 - 2016/12/31 |
"
// * 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 and Reason for Visit Section"
// * section[=].code = http://loinc.org#46239-0 "Chief complaint and reason for visit"
// * section[=].text.status = #generated
// * section[=].text.div = "Cramping, bloating, and constipation.
"
// * section[+].title = "Admission Diagnosis Section"
// * section[=].code = http://loinc.org#46241-6 "Hospital admission diagnosis"
// * section[=].text.status = #generated
// * section[=].text.div = ""
// * section[+].title = "Admission Medications Section"
// * section[=].code = http://loinc.org#42346-7 "Medications on admission"
// * section[=].text.status = #generated
// * section[=].text.div = "| Medication | Directions | Start Date | Status | Indications | Fill Instructions |
| Pepcid Complete (MAGNESIUM HYDROXIDE0 | Chew one tablet completely and swallow as needed | 20160615 | Active | Bloating | Generic substitution allowed |
"
// * section[+].title = "Encounters Section"
// * section[=].code = http://loinc.org#46240-8 "Encounters"
// * section[=].text.status = #generated
// * section[=].text.div = "| Encounter | Performer | Location | Date |
| Checkup Examination | Dr. S. Steene | Community Urgent Care Center | 2015/09/26 |
"
// * section[+].title = "History of Past Illness Section"
// * section[=].code = http://loinc.org#11348-0 "History of past illness"
// * section[=].text.status = #generated
// * section[=].text.div = "| Problem Name | Type | Onset Date | Abatement Date | Status |
| Fever | Condition | 2016-04-01 | 2016-04-14 | Complete |
"
// * section[=].entry = Reference(Condition/condition-problem)
// * section[+].title = "History of Present Illness Section"
// * section[=].code = http://loinc.org#10164-2 "History of present illness"
// * section[=].text.status = #generated
// * section[=].text.div = "This patient was only recently discharged for a recurrent GI bleed as described below.
He presented to the ER today c/o a dark stool yesterday but a normal brown\n stool today. On exam he was hypotensive in the 80?s resolved after .... .... ....
Lab at discharge: Glucose 112, BUN 16, creatinine 1.1, electrolytes normal.\n H. pylori antibody pending. Admission hematocrit 16%, discharge hematocrit 29%. WBC\n 7300, platelet count 256,000. Urinalysis normal. Urine culture: No growth. INR 1.1,\n PTT 40.
He was transfused with 6 units of packed red blood cells with .... .... ....
GI evaluation 12 September: Colonoscopy showed single red clot in .... ........
"
// * section[+].title = "Family History Section"
// * section[=].code = http://loinc.org#10157-6 "History of family member diseases"
// * section[=].text.status = #generated
// * section[=].text.div = "| Relationship | Diagnosis | Age at Onset |
| Father | Myocardial Infarction(cause of Death) | 57 |
| Father | Diabetes | 40 |
"
// * section[+].title = "Social History Section"
// * section[=].code = http://loinc.org#29762-2 "Social history"
// * section[=].text.status = #generated
// * section[=].text.div = "| Social History Element | Description | Effective Dates |
| Smoking | 1 pack tobacco per day | 2005/05/01 - 2010/02/28 |
"
// * section[=].entry = Reference(Observation/observation-smoker)
// * section[+].title = "Functional Status Section"
// * section[=].code = http://loinc.org#47420-5 "Functional status"
// * section[=].text.status = #generated
// * section[=].text.div = "| Functional or Cognitive Finding | Observation | Observation Date | Condition Status |
| Ambulation (Dependent to Independent | Independently able | 2010/03/11 | Active |
| Finding of Functional Performance and Activity | Dyspnea | 2008/02/16 | Active |
| Cognitive Function Finding | Memory Impairment | 2014/04/29 | Active |
"
// * section[+].title = "General Status Section"
// * section[=].code = http://loinc.org#10210-3 "Physical findings of General status"
// * section[=].text.status = #generated
// * section[=].text.div = "Alert and in good spirits, no acute distress.
"
// * section[+].title = "Mental Status Section"
// * section[=].code = http://loinc.org#10190-7 "Mental status"
// * section[=].text.status = #generated
// * section[=].text.div = "| Mental Status Findings | Effective Dates | Condition Status |
| Mental Function | July 31, 2013 | Impaired |
| Cognitive Abilities | July 31, 2013 | Judgement, Intact |
| Cognitive Function | July 31, 2013 | Aggressive Behavior |
| Cognitive Function | July 31, 2013 | Difficulty understanding own emotions |
| Cognitive Function | July 31, 2013 | Difficulty communicating Thoughts |
"
// * section[+].title = "Medical Equipment Section"
// * section[=].code = http://loinc.org#46264-8 "Medical equipment"
// * section[=].text.status = #generated
// * section[=].text.div = "| Supply/Device | Date Supplied |
| Automatic Implantable cardioverter/defbrillator | 2008/11/16 |
| Wheelchair | 1999/12/01 |
"
// * section[+].title = "Medication Section"
// * section[=].code = http://loinc.org#10160-0 "History of Medication Use"
// * section[=].text.status = #generated
// * section[=].text.div = "| Medication | Directions | Start Date | Status | Indications | Fill Instructions |
| Amoxicillin | Amoxicillin Powder, for Suspension 250mg/5ml | 20160401 | Active | Pneumonia | Generic substitution allowed |
"
// * section[=].entry = Reference(MedicationStatement/medication-statement)
// * section[+].title = "Payers Section"
// * section[=].code = http://loinc.org#48768-6 "Payers"
// * section[=].text.status = #generated
// * section[=].text.div = "| Payer Name | Policy ID | Policy Holder |
| United Healthcare | 12341 | Self |
| Cigna | 53123 | Spouse |
"
// * section[+].title = "Plan of Treatment Section"
// * section[=].code = http://loinc.org#18776-5 "Plan of treatment"
// * section[=].text.status = #generated
// * section[=].text.div = "| Planned Activity | Period | Status |
| Colonoscopy | 2016/08/16 - 2016/08/16 | Completed |
| Recommendation to Exercise | 2016/10/29 | Ongoing |
"
// * section[+].title = "Problem Section"
// * section[=].code = http://loinc.org#11450-4 "Problem list"
// * section[=].text.status = #generated
// * section[=].text.div = "| Problem Name | Type | Onset Date | Abatement Date | Status |
| Fever | Condition | 2016-04-01 | 2016-04-14 | Complete |
"
// * 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 Name | Body Site | Performer | Date Performed | Reason |
| Appendectomy (Procedure) | Abdomen | Dr. Adam Everyman | 20160405 | Generalized abdominal pain 24 hours. Localized in RIF with rebound and guarding |
"
// * section[=].entry = Reference(Procedure/procedure-rehab)
// * section[+].title = "Discharge Diagnosis Section"
// * section[=].code = http://loinc.org#11535-2 "Hospital discharge diagnosis"
// * section[=].text.status = #generated
// * section[=].text.div = ""
// * section[+].title = "Discharge Medications Section (entries required)"
// * section[=].code = http://loinc.org#10183-2 "Hospital discharge medications"
// * section[=].text.status = #generated
// * section[=].text.div = "| Medication | Directions | Start Date | Status | Indications | Fill Instructions |
| Acetaminophen Tab 325 mg | Take 2 tablet(s) every four hours if needed | 20150615 | Active | Pain management | Generic substitution allowed |
"
// * section[+].title = "Immunizations Section"
// * section[=].code = http://loinc.org#11369-6 "History of immunization"
// * section[=].text.status = #generated
// * section[=].text.div = "| Vaccine | Date | Status |
| Fluvax (Influenza) | 2016-04-05 | Completed |
"
// * 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 = "| Date | Nutritional Status | Diet |
| 2005/12/29 | Well nourished | Low sodium diet, excessive carbohydrate |
| 2010/05/26 | Slight dehydration | High protein, low fibre |
"
// * section[+].title = "Reason for Referral Section"
// * section[=].code = http://loinc.org#42349-1 "Reason for Referral"
// * section[=].text.status = #generated
// * section[=].text.div = ""
// * 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 Type | Quantity Value | Date | Status |
| Glucose [Moles/volume] in Blood | 6.3 mmol/l | 2016/06/15 | Final |
"
// * 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 Sign | Date | Value |
| Temperature | 2016/06/15 | 39 Degrees Celcius |
"
// * section[=].entry = Reference(Observation/observation-vitals-temp)