<section> <code> <coding> <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/> <code value="registration-arrival"/> </coding> </code> <entry> <reference value="Encounter/em-ed-encounter-example"/> </entry> </section> <section> <code> <coding> <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/> <code value="triage-vitals"/> </coding> </code> <entry> <reference value="Observation/em-ed-vitals-arrival-hr-example"/> </entry> <entry> <reference value="Observation/em-ed-high-risk-signs-example"/> </entry> </section> <section> <code> <coding> <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/> <code value="chief-complaint-referral"/> </coding> </code> <entry> <reference value="Condition/em-ed-condition-chief-complaint-example"/> </entry> </section> <section> <code> <coding> <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/> <code value="allergies"/> </coding> </code> <entry> <reference value="AllergyIntolerance/em-allergy-example-valid"/> </entry> </section> <section> <code> <coding> <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/> <code value="past-medical-history"/> </coding> </code> <entry> <reference value="Condition/em-ed-condition-past-medical-history-example"/> </entry> </section> <section> <code> <coding> <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/> <code value="provider-assessment-abcde"/> </coding> </code> <entry> <reference value="Observation/em-ed-abcde-breathing-example"/> </entry> <entry> <reference value="Observation/em-ed-abcde-circulation-example"/> </entry> <entry> <reference value="Procedure/em-ed-procedure-chest-tube-example"/> </entry> <entry> <reference value="MedicationAdministration/em-ed-medication-analgesia-example"/> </entry> </section> <section> <code> <coding> <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/> <code value="history-of-present-illness"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">Patient reports sudden onset right-sided chest pain and shortness of breath following a road traffic collision approximately 45 minutes prior to arrival.</div> </text> </section> <section> <code> <coding> <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/> <code value="trauma"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">Road traffic crash, unintentional. See the traumaDetails extension on the referenced EMEDEncounter for coded mechanism/intent.</div> </text> </section> <section> <code> <coding> <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/> <code value="review-of-systems"/> </coding> </code> <entry> <reference value="Observation/em-ed-ros-respiratory-example"/> </entry> <entry> <reference value="Observation/em-ed-ros-gi-example"/> </entry> </section> <section> <code> <coding> <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/> <code value="physical-exam"/> </coding> </code> <entry> <reference value="Observation/em-ed-physical-exam-respiratory-example"/> </entry> <entry> <reference value="Observation/em-ed-physical-exam-general-example"/> </entry> </section> <section> <code> <coding> <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/> <code value="diagnostic-tests"/> </coding> </code> <entry> <reference value="DiagnosticReport/em-ed-diagnostic-report-cbc-example"/> </entry> <entry> <reference value="Observation/em-ed-pocus-chest-example"/> </entry> <entry> <reference value="Observation/em-ed-urinalysis-example"/> </entry> </section> <section> <code> <coding> <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/> <code value="procedures"/> </coding> </code> <entry> <reference value="Procedure/em-ed-procedure-chest-tube-example"/> </entry> </section> <section> <code> <coding> <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/> <code value="medications"/> </coding> </code> <entry> <reference value="MedicationAdministration/em-ed-medication-analgesia-example"/> </entry> </section> <section> <code> <coding> <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/> <code value="diagnosis-impression"/> </coding> </code> <entry> <reference value="Condition/em-ed-condition-discharge-diagnosis-example"/> </entry> </section> <section> <code> <coding> <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/> <code value="management-plan"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">Chest tube inserted for right pneumothorax; admit to ICU for observation; repeat chest X-ray in 4 hours.</div> </text> </section> <section> <code> <coding> <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/> <code value="final-reassessment"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">Improved perfusion and reduced work of breathing following chest tube insertion.</div> </text> <entry> <reference value="Observation/em-ed-vitals-final-hr-example"/> </entry> </section> <section> <code> <coding> <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/> <code value="disposition"/> </coding> </code> <text> <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">Admitted to ICU for further management of traumatic pneumothorax.</div> </text> <entry> <reference value="Encounter/em-ed-encounter-example"/> </entry> </section> </Composition>

Generated Narrative: Composition em-ed-patient-record-composition-example

Profile: Composition - Emergency Department Patient Record

status: Final

type: Emergency department Note

encounter: Encounter: extension = Government insurance,Ambulance,Non-ambulatory,Acute,false,,; identifier = http://hie.go.ke/fhir/identifier/hospital-registration-number#KNH-ED-2026-004417; status = finished; class = emergency (ActCode#EMER); priority = Orange - Very urgent; period = 2026-06-29 12:40:00+0300 --> 2026-06-29 14:10:00+0300

date: 2026-06-29 14:10:00+0300

author:

title: Emergency Department Patient Record - Amina Atieno - 2026-06-29


  
    
  
  
    
  
  
  
    
  
  
    
  
  
  <section>
    <code>
      <coding>
        <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/>
        <code value="registration-arrival"/>
      </coding>
    </code>
    <entry>
      <reference value="Encounter/em-ed-encounter-example"/>
    </entry>
  </section>
  <section>
    <code>
      <coding>
        <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/>
        <code value="triage-vitals"/>
      </coding>
    </code>
    <entry>
      <reference value="Observation/em-ed-vitals-arrival-hr-example"/>
    </entry>
    <entry>
      <reference value="Observation/em-ed-high-risk-signs-example"/>
    </entry>
  </section>
  <section>
    <code>
      <coding>
        <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/>
        <code value="chief-complaint-referral"/>
      </coding>
    </code>
    <entry>
      <reference value="Condition/em-ed-condition-chief-complaint-example"/>
    </entry>
  </section>
  <section>
    <code>
      <coding>
        <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/>
        <code value="allergies"/>
      </coding>
    </code>
    <entry>
      <reference value="AllergyIntolerance/em-allergy-example-valid"/>
    </entry>
  </section>
  <section>
    <code>
      <coding>
        <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/>
        <code value="past-medical-history"/>
      </coding>
    </code>
    <entry>
      <reference value="Condition/em-ed-condition-past-medical-history-example"/>
    </entry>
  </section>
  <section>
    <code>
      <coding>
        <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/>
        <code value="provider-assessment-abcde"/>
      </coding>
    </code>
    <entry>
      <reference value="Observation/em-ed-abcde-breathing-example"/>
    </entry>
    <entry>
      <reference value="Observation/em-ed-abcde-circulation-example"/>
    </entry>
    <entry>
      <reference value="Procedure/em-ed-procedure-chest-tube-example"/>
    </entry>
    <entry>
      <reference value="MedicationAdministration/em-ed-medication-analgesia-example"/>
    </entry>
  </section>
  <section>
    <code>
      <coding>
        <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/>
        <code value="history-of-present-illness"/>
      </coding>
    </code>
    <text>
      <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">Patient reports sudden onset right-sided chest pain and shortness of breath following a road traffic collision approximately 45 minutes prior to arrival.</div>
    </text>
  </section>
  <section>
    <code>
      <coding>
        <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/>
        <code value="trauma"/>
      </coding>
    </code>
    <text>
      <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">Road traffic crash, unintentional. See the traumaDetails extension on the referenced EMEDEncounter for coded mechanism/intent.</div>
    </text>
  </section>
  <section>
    <code>
      <coding>
        <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/>
        <code value="review-of-systems"/>
      </coding>
    </code>
    <entry>
      <reference value="Observation/em-ed-ros-respiratory-example"/>
    </entry>
    <entry>
      <reference value="Observation/em-ed-ros-gi-example"/>
    </entry>
  </section>
  <section>
    <code>
      <coding>
        <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/>
        <code value="physical-exam"/>
      </coding>
    </code>
    <entry>
      <reference value="Observation/em-ed-physical-exam-respiratory-example"/>
    </entry>
    <entry>
      <reference value="Observation/em-ed-physical-exam-general-example"/>
    </entry>
  </section>
  <section>
    <code>
      <coding>
        <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/>
        <code value="diagnostic-tests"/>
      </coding>
    </code>
    <entry>
      <reference value="DiagnosticReport/em-ed-diagnostic-report-cbc-example"/>
    </entry>
    <entry>
      <reference value="Observation/em-ed-pocus-chest-example"/>
    </entry>
    <entry>
      <reference value="Observation/em-ed-urinalysis-example"/>
    </entry>
  </section>
  <section>
    <code>
      <coding>
        <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/>
        <code value="procedures"/>
      </coding>
    </code>
    <entry>
      <reference value="Procedure/em-ed-procedure-chest-tube-example"/>
    </entry>
  </section>
  <section>
    <code>
      <coding>
        <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/>
        <code value="medications"/>
      </coding>
    </code>
    <entry>
      <reference value="MedicationAdministration/em-ed-medication-analgesia-example"/>
    </entry>
  </section>
  <section>
    <code>
      <coding>
        <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/>
        <code value="diagnosis-impression"/>
      </coding>
    </code>
    <entry>
      <reference value="Condition/em-ed-condition-discharge-diagnosis-example"/>
    </entry>
  </section>
  <section>
    <code>
      <coding>
        <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/>
        <code value="management-plan"/>
      </coding>
    </code>
    <text>
      <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">Chest tube inserted for right pneumothorax; admit to ICU for observation; repeat chest X-ray in 4 hours.</div>
    </text>
  </section>
  <section>
    <code>
      <coding>
        <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/>
        <code value="final-reassessment"/>
      </coding>
    </code>
    <text>
      <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">Improved perfusion and reduced work of breathing following chest tube insertion.</div>
    </text>
    <entry>
      <reference value="Observation/em-ed-vitals-final-hr-example"/>
    </entry>
  </section>
  <section>
    <code>
      <coding>
        <system value="https://fhir.dha.go.ke/ig/emergency/CodeSystem/em-ed-section"/>
        <code value="disposition"/>
      </coding>
    </code>
    <text>
      <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">Admitted to ICU for further management of traumatic pneumothorax.</div>
    </text>
    <entry>
      <reference value="Encounter/em-ed-encounter-example"/>
    </entry>
  </section>
</Composition>