// Instance: Consultation-Note-Example // InstanceOf: Composition // Description: "John Doe - Composition - Consultation 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-Consultation-Note" // * language = #en-US // * identifier.system = "urn:ietf:rfc:3986" // * identifier.value = "12345" // * status = #preliminary // * type = http://loinc.org#11488-4 "Consult Note" // * subject = Reference(Patient/john-doe) "John Doe" // * encounter = Reference(Encounter/encounter-1) "Encounter with patient Amy V. Shaw" // * date = "2016-02-28T09:10:14Z" // * author = Reference(Practitioner/practitioner-1) "Ronald Boone, MD" // * title = "Consultation 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) "Acme Labs" // * event.code = http://hl7.org/fhir/v3/ActClass#PCPR "Care Provision" // * event.period.start = "2015-11-18" // * event.period.end = "2015-12-12" // * section[0].title = "Advance Directives Section" // * section[=].code = http://loinc.org#42348-3 "Advance directives" // * section[=].text.status = #generated // * section[=].text.div = "
NameApplies Period
Resuscitation2015/01/01 - 2016/12/31
" // * section[+].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 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 = "Chief Complaint Section" // * section[=].code = http://loinc.org#10154-3 "Chief complaint" // * section[=].text.status = #generated // * section[=].text.div = "

Dark Stools

" // * 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[=].entry = Reference(http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory) // * section[+].title = "Functional Status Section" // * section[=].code = http://loinc.org#47420-5 "Functional status" // * section[=].text.status = #generated // * section[=].text.div = "
Functional or Cognitive FindingObservationObservation DateCondition Status
Ambulation (Dependent to IndependentIndependently able2010/03/11Active
Finding of Functional Performance and ActivityDyspnea2008/02/16Active
Cognitive Function FindingMemory Impairment2014/04/29Active
" // * 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 = "History of Past Illness Section" // * section[=].code = http://loinc.org#11348-0 "History of past illness" // * section[=].text.status = #generated // * section[=].text.div = "

See History of Present Illness

" // * 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 = "Immunizations Section" // * section[=].code = http://loinc.org#11369-6 "History of immunization" // * section[=].text.status = #generated // * section[=].text.div = "
VaccineDateStatus
Fluvax (Influenza)2016-04-05Completed
" // * section[=].entry = Reference(Immunization/immunization) // * 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/defbrillator2008/11/16
Wheelchair1999/12/01
" // * 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 = "Mental Status Section" // * section[=].code = http://loinc.org#10190-7 "Mental status" // * section[=].text.status = #generated // * section[=].text.div = "
Mental Status FindingsEffective DatesCondition Status
Mental FunctionJuly 31, 2013Impaired
Cognitive AbilitiesJuly 31, 2013Judgement, Intact
Cognitive FunctionJuly 31, 2013Aggressive Behavior
Cognitive FunctionJuly 31, 2013Difficulty understanding own emotions
Cognitive FunctionJuly 31, 2013Difficulty communicating Thoughts
" // * 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 = "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 = "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 Everyman20160405Generalized abdominal pain 24 hours. Localized in RIF with rebound and guarding
" // * section[=].entry = Reference(Procedure/procedure-rehab) // * section[+].title = "Reason for Visit Section" // * section[=].code = http://loinc.org#29299-5 "Reason for visit" // * section[=].text.status = #generated // * section[=].text.div = "

Tenderness of lower abdomen

" // * 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/l2016/04/01Final
" // * section[=].entry = Reference(Observation/observation-lab-urine) // * 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 = "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 day2005/05/01 - 2010/02/28
" // * section[=].entry = Reference(Observation/observation-smoker) // * section[+].title = "Vital Signs Section" // * section[=].code = http://loinc.org#8716-3 "Vital signs" // * section[=].text.status = #generated // * section[=].text.div = "
Vital SignDateValue
Temperature2016/04/0539 Degrees Celcius
" // * section[=].entry = Reference(Observation/observation-vitals-temp)