MyHealtheVet PHR FHIR API
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MyHealtheVet PHR FHIR API, published by VA Digital Services. This guide is not an authorized publication; it is the continuous build for version 0.3.9-current built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/department-of-veterans-affairs/mhv-fhir-phr-mapping/ and changes regularly. See the Directory of published versions

Example DocumentReference: Note 5

Page standards status: Informative

This is a sample of a note that was signed, and for which an addenda is being added. Given that the addenda is not signed, the text body indicates that there is an addenda that is not accessible. This addenda is signed in note-6.

Derived from the following mock NoteTO:

<noteTO>
    <id>5298388</id>
    <timestamp>3231116.144</timestamp>
    <localTitle>STAGING (TNM) URINARY BLADDER</localTitle>
    <author>
        <id>36556</id>
        <name>AHMED,MARUF</name>
    </author>
    <location>
        <id>984ZZI</id>
        <name>ZZDAYTSHR</name>
    </location>
    <text>LOCAL TITLE: STAGING (TNM) URINARY BLADDER                      
DATE OF NOTE: NOV 16, 2023@14:40     ENTRY DATE: NOV 16, 2023@14:40:47      
      AUTHOR: AHMED,MARUF          EXP COSIGNER:                           
     URGENCY:                            STATUS: COMPLETED                     

   *** STAGING (TNM) URINARY BLADDER Has ADDENDA ***

URINARY BLADDER
6th edition AJCC Cancer Staging Manual


testing note with kbst team
 
CLIN   PATH     PRIMARY TUMOR (T)
 [X]   [ ]   TX      Primary tumor cannot be assessed
 [ ]   [ ]   T0      No evidence of primary tumor
 [ ]   [ ]   Ta      Non invasive papillary carcinoma
 [ ]   [ ]   Tis     Carcinoma in situ (flat tumor)
 [X]   [ ]   T1      Tumor invades subepithelial connective tissue
 [ ]   [ ]   T2      Tumor invades muscle
 [ ]   [ ]           T2a     Tumor Invades superficial (inner half)
 [ ]   [ ]           T2b     Tumor Invades deep muscle (outer half)
 [ ]   [X]   T3      Tumor invades perivesical tissue
 [ ]   [X]           T3a     Microscopically
 [ ]   [ ]           T3b     Macroscopically (extravesical mass)
 [ ]   [ ]   T4      Tumor invades any of the following: prostate,
                       uterus, vagina, pelvic or abdominal wall
 [ ]   [ ]           T4a     Tumor invades prostate, uterus, vagina
 [X]   [X]           T4b     Tumor invades pelvic wall, abdominal wall
 
 
               REGIONAL LYMPH NODES (N)
 [ ]   [ ]   NX      Regional lymph node metastasis cannot be assessed
 [ ]   [ ]   N0      No regional lymph node metastasis
 [ ]   [X]   N1      Mets in a single lymph node, 2 cm or less in
                       greatest dimension.
 [ ]   [X]   N2      Mets in a single lymph node more than 2 but not
                       more than 5 cm in greatest dimension; multiple
                       lymph nodes, none more than 5 cm in greatest
                       dimension.
 [ ]   [ ]   N3      Metastasis in a lymph node more than 5 cm
 
               DISTANT METASTASIS (M)
 [ ]   [X]   MX      Presence of distant metastasis cannot be assessed
 [ ]   [X]   M0      No distant metastasis
 [ ]   [ ]   M1      Distant metastasis
 
STAGE GROUPING
 [ ]   [ ]   Oa      Ta      N0      M0
 [ ]   [ ]   Ois     Tis     N0      M0
 [ ]   [ ]   I       T1      N0      M0
 [ ]   [X]   II      T2a     N0      M0
 [ ]   [ ]           T2b     N0      M0
 [ ]   [ ]   III     T3a     N0      M0
 [ ]   [X]           T3b     N0      M0
 [ ]   [ ]           T4a     N0      M0
 [ ]   [ ]   IV      T4b     N0      M0
 [X]   [ ]           Any T   N1      M0
 [X]   [ ]           Any T   N2      M0
 [X]   [ ]           Any T   N3      M0
 [X]   [ ]           Any T   Any N   M1
 
                       GRADE
        [ ]   GX      Grade cannot be assessed
        [X]   G1      Well differentiated
        [X]   G2      Mod differentiated
        [ ]   G3      Poorly differentiated
        [ ]   G4      Undifferentiated
 
 
OP #598c (552) Approved 12/99 Rev 03/03
 
/es/ MARUF AHMED
PHYSICIAN
Signed: 11/16/2023 14:50

11/16/2023 ADDENDUM                      STATUS: UNSIGNED
 You may not VIEW this UNSIGNED Addendum.</text>
    <approvedBy>
        <id>36556</id>
        <name>AHMED,MARUF</name>
        <signature>MARUF AHMED PHYSICIAN</signature>
    </approvedBy>
    <status>completed</status>
    <type>PN</type>
    <procTimestamp>3231116.145026</procTimestamp>
</noteTO>

Generated Narrative: DocumentReference ex-MHV-note-5

identifier: urn:oid:2.16.840.1.113883.4.349.4.989/NoteTO.5298388 (use: usual, )

status: Current

type: Progress note

category: Clinical Note

subject: MTPZEROTWO DAYTSHR Male, DoB: 1000-01-01 ( urn:oid:2.16.840.1.113883.4.349#1 (use: usual, ))

date: 2023-11-16 14:40:00+0000

author: Practitioner AHMED,MARUF

authenticator: Practitioner AHMED,MARUF

content

Attachments

-ContentTypeDataTitle
*text/plain(base64 data - 4,160 base64 chars)STAGING (TNM) URINARY BLADDER

Contexts

-Related
*Location DAYTSHR TEST LAB

Generated Narrative: Practitioner #ex-MHV-practitioner-36556

identifier: urn:oid:2.16.840.1.113883.4.349.4.989/AuthorTO.37556 (use: usual, )

name: AHMED,MARUF


Generated Narrative: Location #ex-MHV-location-984

identifier: urn:oid:2.16.840.1.113883.4.349.4.989/HospitalLocationTO.984 (use: usual, )

name: DAYTSHR TEST LAB