# Betsy Smith-Johnson Discharge Summary - PACIO Sample Data Depot v0.1.0

* [**Table of Contents**](toc.md)
* [**Artifacts Summary**](artifacts.md)
* **Betsy Smith-Johnson Discharge Summary**

## Example Composition: Betsy Smith-Johnson Discharge Summary

Language: en-US

Profile: [Discharge Summaryversion: null2.0.0-ballot)](http://hl7.org/fhir/us/ccda/2025Jan/StructureDefinition-Discharge-Summary.html)

**identifier**: [Uniform Resource Identifier (URI)](http://terminology.hl7.org/6.1.0/NamingSystem-uri.html)/urn:uuid:03d0f89e-b0ac-482b-a400-c436df8055e3

**status**: Preliminary

**type**: Discharge Summary

**date**: 2025-05-04 15:15:00+0000

**author**: [Priya Sarkar, MD](PractitionerRole-PractitionerRole-Physician-PriyaSarkar.md)

**title**: Betsy Smith-Johnson Discharge Summary

**custodian**: [Metro Hospital Emergency Department](Organization-org-ED-Metro-Hospital.md)



## Resource Content

```json
{
  "resourceType" : "Composition",
  "id" : "BSJ1-composition-CCDA-dischargeSummary-01",
  "meta" : {
    "profile" : [
      "http://hl7.org/fhir/us/ccda/StructureDefinition/Discharge-Summary|2.0.0-ballot"
    ]
  },
  "language" : "en-US",
  "identifier" : {
    "system" : "urn:ietf:rfc:3986",
    "value" : "urn:uuid:03d0f89e-b0ac-482b-a400-c436df8055e3"
  },
  "status" : "preliminary",
  "type" : {
    "coding" : [
      {
        "system" : "http://loinc.org",
        "code" : "18842-5",
        "display" : "Discharge Summary"
      }
    ]
  },
  "subject" : {
    "reference" : "Patient/patient-betsysmith-johnson01",
    "display" : "Betsy Smith-Johnson"
  },
  "date" : "2025-05-04T15:15:00.000+00:00",
  "author" : [
    {
      "reference" : "PractitionerRole/PractitionerRole-Physician-PriyaSarkar",
      "display" : "Priya Sarkar, MD"
    }
  ],
  "title" : "Betsy Smith-Johnson Discharge Summary",
  "custodian" : {
    "reference" : "Organization/org-ED-Metro-Hospital",
    "display" : "Metro Hospital Emergency Department"
  },
  "section" : [
    {
      "title" : "Allergies and Intolerances Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "48765-2",
            "display" : "Allergies and adverse reactions Document"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Allergies for Betsy Smith Johnson</div>"
      },
      "entry" : [
        {
          "reference" : "AllergyIntolerance/betsysmith-johnson01-AllergyACE"
        }
      ]
    },
    {
      "title" : "Chief Complaint and Reason for Visit Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "46239-0",
            "display" : "Chief complaint+Reason for visit Narrative"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Chief complaint and reason for visit for Betsy Smith Johnson</div>"
      },
      "entry" : [
        {
          "reference" : "DocumentReference/BSJ1-documentReference-ED-AdminAssessment-01"
        }
      ]
    },
    {
      "title" : "Chief Complaint Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "10154-3",
            "display" : "Chief complaint Narrative - Reported"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Chief complaint for Betsy Smith Johnson</div>"
      }
    },
    {
      "title" : "Reason for Visit Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "29299-5",
            "display" : "Reason for visit"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Reason for visit for Betsy Smith Johnson</div>"
      }
    },
    {
      "title" : "Admission Diagnosis Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "46241-6",
            "display" : "Hospital admission diagnosis Narrative - Reported"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Admission diagnosis for Betsy Smith Johnson</div>"
      }
    },
    {
      "title" : "Admission Medications Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "42346-7",
            "display" : "Medications on admission (narrative)"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Medications on admission for Betsy Smith Johnson</div>"
      }
    },
    {
      "title" : "Past Medical History Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "11348-0",
            "display" : "History of Past illness Narrative"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Past Medical History for Betsy Smith Johnson</div>"
      },
      "entry" : [
        {
          "reference" : "Condition/betsysmith-johnson01-Condition-BreastCancer-01",
          "display" : "Breast Cancer"
        }
      ]
    },
    {
      "title" : "History of Present Illness Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "10164-2",
            "display" : "History of Present illness Narrative"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">History of present illness for Betsy Smith Johnson</div>"
      }
    },
    {
      "title" : "Review of Systems Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "10187-3",
            "display" : "Review of systems"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Review of systems for Betsy Smith Johnson</div>"
      }
    },
    {
      "title" : "Family History Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "10157-6",
            "display" : "History of family member diseases Narrative"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Family history for Betsy Smith Johnson</div>"
      }
    },
    {
      "title" : "Social History Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "29762-2",
            "display" : "Social history Narrative"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Social history for Betsy Smith Johnson</div>"
      }
    },
    {
      "title" : "Functional Status Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "47420-5",
            "display" : "Functional status assessment note"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Functional status assessment for Betsy Smith Johnson</div>"
      }
    },
    {
      "title" : "Hospital Course Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "8648-8",
            "display" : "Hospital course"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Hospital course for Betsy Smith Johnson</div>"
      }
    },
    {
      "title" : "Hospital Consultations Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "18841-7",
            "display" : "Hospital consultations Document"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Hospital consultations for Betsy Smith Johnson</div>"
      }
    },
    {
      "title" : "Plan of Treatment Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "18776-5",
            "display" : "Plan of care note"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Plan of treatment for Betsy Smith Johnson</div>"
      }
    },
    {
      "title" : "Problem Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "11450-4",
            "display" : "Problem list - Reported"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Problem list for Betsy Smith Johnson</div>"
      },
      "entry" : [
        {
          "reference" : "Condition/betsysmith-johnson01-Condition-Hemiparesis-01",
          "display" : "Hemiparesis"
        },
        {
          "reference" : "Condition/betsysmith-johnson01-Condition-Diabetes-01",
          "display" : "Diabetes"
        },
        {
          "reference" : "Condition/betsysmith-johnson01-Condition-Hypertension-01",
          "display" : "Hypertension"
        },
        {
          "reference" : "Condition/betsysmith-johnson01-Condition-Hyperlipidemia-01",
          "display" : "Hyperlipidemia"
        },
        {
          "reference" : "Condition/betsysmith-johnson01-Condition-Depression-01",
          "display" : "Depression"
        },
        {
          "reference" : "Condition/betsysmith-johnson01-Condition-KidneyDisease-01",
          "display" : "Kidney Disease"
        },
        {
          "reference" : "Condition/betsysmith-johnson01-Condition-Osteoarthritis-01",
          "display" : "Osteoarthritis"
        },
        {
          "reference" : "Condition/betsysmith-johnson01-Condition-Osteopenia-01",
          "display" : "Osteopenia"
        },
        {
          "reference" : "Condition/betsysmith-johnson01-condition-IschemicStrokeDiagnosis-01",
          "display" : "Ischemic Stroke"
        }
      ]
    },
    {
      "title" : "Procedures Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "47519-4",
            "display" : "History of Procedures Document"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Procedures for Betsy Smith Johnson</div>"
      }
    },
    {
      "title" : "Discharge Diagnosis Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "11535-2",
            "display" : "Hospital discharge Dx Narrative"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Discharge diagnosis for Betsy Smith Johnson</div>"
      }
    },
    {
      "title" : "Discharge Medications Section (entries required)",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "10183-2",
            "display" : "Hospital discharge medications"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Discharge medications for Betsy Smith Johnson</div>"
      }
    },
    {
      "title" : "Hospital Discharge Instructions Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "8653-8",
            "display" : "Hospital discharge instructions"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Hospital discharge instructions for Betsy Smith Johnson</div>"
      }
    },
    {
      "title" : "Hospital Discharge Physical Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "10184-0",
            "display" : "Hospital discharge physical findings Narrative"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Hospital discharge physical findings for Betsy Smith Johnson</div>"
      }
    },
    {
      "title" : "Hospital Discharge Studies Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "11493-4",
            "display" : "Hospital discharge studies summary"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Hospital discharge studies for Betsy Smith Johnson</div>"
      }
    },
    {
      "title" : "Immunizations Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "11369-6",
            "display" : "History of Immunization Narrative"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Immunizations for Betsy Smith Johnson</div>"
      }
    },
    {
      "title" : "Nutrition Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "61144-2",
            "display" : "Diet and nutrition Narrative"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Nutrition for Betsy Smith Johnson</div>"
      }
    },
    {
      "title" : "Vital Signs Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "8716-3",
            "display" : "Vital signs"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Vital signs for Betsy Smith Johnson</div>"
      },
      "entry" : [
        {
          "reference" : "Observation/betsysmith-johnson01-observation-bodyweight-01"
        },
        {
          "reference" : "Observation/betsysmith-johnson01-observation-bodyheight-01"
        },
        {
          "reference" : "Observation/betsysmith-johnson01-observation-bmi-01"
        },
        {
          "reference" : "Observation/betsysmith-johnson01-observation-bp-01"
        },
        {
          "reference" : "Observation/betsysmith-johnson01-observation-heartrate-01"
        },
        {
          "reference" : "Observation/betsysmith-johnson01-observation-respirationrate-01"
        },
        {
          "reference" : "Observation/betsysmith-johnson01-observation-bodytemp-01"
        },
        {
          "reference" : "Observation/betsysmith-johnson01-observation-oxygensat-01"
        }
      ]
    }
  ]
}

```
