Cross Border Data Exchange IG
1.0.0 - CI Build International flag

Cross Border Data Exchange IG, published by IEHR-Workgroup. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/InteropEHRate-project/cross-border-data-exchange/ and changes regularly. See the Directory of published versions

: MedicalVisitReport Example - XML Representation

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<Composition xmlns="http://hl7.org/fhir">
  <id value="1"/>
  <meta>
    <profile
             value="http://interopehrate.eu/fhir/StructureDefinition/Composition-VisitReport-IEHR"/>
  </meta>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: Composition</b><a name="1"> </a><a name="hc1"> </a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Composition &quot;1&quot; </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-Composition-VisitReport-IEHR.html">VisitReport-IEHR</a></p></div><p><b>ProvenanceExtension-IEHR</b>: <a href="Provenance-38.html">Provenance/38</a></p><p><b>status</b>: final</p><p><b>type</b>: Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://loinc.org/">LOINC</a>#81214-9)</span></p><p><b>encounter</b>: <a href="Encounter-1.html">Encounter/1</a></p><p><b>date</b>: 2022-07-05 09:49:37+0200</p><p><b>author</b>: <a href="Practitioner-21.html">Practitioner/21</a> &quot; ANTONIO&quot;</p><p><b>title</b>: Medical visit</p></div>
  </text>
  <extension
             url="http://interopehrate.eu/fhir/StructureDefinition/ProvenanceExtension-IEHR">
    <valueReference>🔗 
      <reference value="Provenance/38"/>
    </valueReference>
  </extension>
  <status value="final"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="81214-9"/>
      <display
               value="Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections"/>
    </coding>
  </type>
  <encounter>🔗 
    <reference value="Encounter/1"/>
  </encounter>
  <date value="2022-07-05T09:49:37+02:00"/>
  <author>🔗 
    <reference value="Practitioner/21"/>
  </author>
  <title value="Medical visit"/>
  <section>
    <title value="Allergies"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="48765-2"/>
        <display value="Allergies and adverse reactions Document"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the Allergies section</div>
    </text>
  </section>
  <section>
    <title value="History of Medication use Narrative"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10160-0"/>
        <display value="Hx of Medication use"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the History of Medication section</div>
    </text>
    <entry>🔗 
      <reference value="MedicationRequest/2"/>
    </entry>
  </section>
  <section>
    <title value="Problem list - Reported"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="11450-4"/>
        <display value="Problem list - Reported"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the Problem list section</div>
    </text>
  </section>
  <section>
    <title value="History of Procedures Document"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="47519-4"/>
        <display value="History of Procedures Document"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the History of Procedures section</div>
    </text>
  </section>
  <section>
    <title value="Relevant diagnostic tests/laboratory data Narrative"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="30954-2"/>
        <display value="Relevant Dx tests/lab data"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the laboratory section section</div>
    </text>
    <entry>🔗 
      <reference value="Observation/1"/>
    </entry>
  </section>
  <section>
    <title value="Social history"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="29762-2"/>
        <display value="Social Hx"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the Social History section</div>
    </text>
  </section>
  <section>
    <title value="Vital signs"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="8716-3"/>
        <display value="Vital signs"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the Vital Signs section</div>
    </text>
  </section>
  <section>
    <title value="Advance directives"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="42348-3"/>
        <display value="Advance directives"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the Advance directives section</div>
    </text>
  </section>
  <section>
    <title value="History of Hospitalizations+Outpatient visits Narrative"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="46240-8"/>
        <display value="Hx of Hospitalizations+OP visits"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the History of Hospitalizations+Outpatient visits section</div>
    </text>
  </section>
  <section>
    <title value="History of family member diseases Narrative"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10157-6"/>
        <display value="Family member diseases Hx"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the History of family disease section</div>
    </text>
  </section>
  <section>
    <title value="Functional status assessment note"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="47420-5"/>
        <display value="Functional status note"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the Functional status section</div>
    </text>
  </section>
  <section>
    <title value="History of Immunization Narrative"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="11369-6"/>
        <display value="Hx of Immunization"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the history of immunization section</div>
    </text>
  </section>
  <section>
    <title value="Mental status Narrative"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10190-7"/>
        <display value="Mental status"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the mental status section</div>
    </text>
  </section>
  <section>
    <title value="History of medical device use"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="46264-8"/>
        <display value="Hx medical device use"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the medical device history section</div>
    </text>
  </section>
  <section>
    <title value="Diet and nutrition Narrative"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="61144-2"/>
        <display value="Diet+nutrition"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the diet and nutrition section</div>
    </text>
  </section>
  <section>
    <title value="Payment sources Document"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="48768-6"/>
        <display value="Payment sources Doc"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the payment document section</div>
    </text>
  </section>
  <section>
    <title value="Plan of care note"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="18776-5"/>
        <display value="Plan of care note"/>
      </coding>
    </code>
    <text>
      <status value="extensions"/>
      <div xmlns="http://www.w3.org/1999/xhtml">This is the plan of care section</div>
    </text>
  </section>
</Composition>