STU 3 Candidate
This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
Example CCD
{
"resourceType": "Composition",
"id": "ccd-example",
"text": {
"status": "generated",
"div": "<div><p><b>Generated Narrative with Details</b></p><p><b>id</b>: ccd-example</p><p><b>identifier</b>: 1</p><p><b>date</b>: 14/02/2016 8:10:14 PM</p><p><b>type</b>: Summary of episode note <span>(Details : {LOINC code '34133-9' = 'Summary of episode note', given as 'Summary of episode note'})</span></p><p><b>title</b>: Continuity of Care Document</p><p><b>status</b>: preliminary</p><p><b>confidentiality</b>: N</p><p><b>author</b>: <a>Adam Everyman, MD</a></p><h3>Attesters</h3><table><tr><td>-</td><td><b>Mode</b></td><td><b>Time</b></td><td><b>Party</b></td></tr><tr><td>*</td><td>legal</td><td>04/01/2012 8:10:14 PM</td><td><a>Adam Everyman, MD</a></td></tr></table><p><b>custodian</b>: <a>Community Health and Hospitals</a></p><h3>Events</h3><table><tr><td>-</td><td><b>Code</b></td><td><b>Period</b></td></tr><tr><td>*</td><td>Care Provision <span>(Details : {http://hl7.org/fhir/v3/ActClass code 'PCPR' = 'care provision', given as 'Care Provision'})</span></td><td>18/11/2015 --> 12/12/2015</td></tr></table><p><b>encounter</b>: <a>http://hl7.org/fhir/daf-encounter</a></p></div>"
},
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/ccda-data-enterer-extension",
"valueUri": "http://fhir2.healthintersections.com.au/open/Practitioner/00929"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/ccda-informant-extension",
"valueUri": "http://fhir2.healthintersections.com.au/open/Practitioner/00929"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/ccda-information-recipient-extension",
"valueUri": "http://fhir2.healthintersections.com.au/open/Practitioner/00929"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/ccda-participant-extension",
"valueUri": "http://fhir2.healthintersections.com.au/open/Practitioner/00929"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/ccda-performer-extension",
"valueUri": "http://fhir2.healthintersections.com.au/open/Practitioner/00929"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/ccda-authorization-extension",
"valueUri": "http://hl7.org/fhir/StructureDefinition/ccda-consent"
}
],
"identifier": {
"system": "http://hl7.org/fhir/StructureDefinition/ccda-ccd-composition",
"value": "1"
},
"date": "2016-02-14T09:10:14Z",
"type": {
"coding": [
{
"system": "http://loinc.org",
"code": "34133-9",
"display": "Summary of episode note"
}
]
},
"title": "Continuity of Care Document",
"status": "preliminary",
"confidentiality": "N",
"subject": {
"reference": "http://fhir2.healthintersections.com.au/open/Patient/1234568501",
"display": "Henry Jones"
},
"author": [
{
"reference": "http://fhir2.healthintersections.com.au/open/Practitioner/00929",
"display": "Adam Everyman, MD"
}
],
"attester": [
{
"mode": [
"legal"
],
"time": "2012-01-04T09:10:14Z",
"party": {
"reference": "http://fhir2.healthintersections.com.au/open/Practitioner/00929",
"display": "Adam Everyman, MD"
}
}
],
"custodian": {
"reference": "http://fhir2.healthintersections.com.au/open/Organization/57",
"display": "Community Health and Hospitals"
},
"event": [
{
"code": [
{
"coding": [
{
"system": "http://hl7.org/fhir/v3/ActClass",
"code": "PCPR",
"display": "Care Provision"
}
]
}
],
"period": {
"start": "2015-11-18",
"end": "2015-12-12"
}
}
],
"encounter": {
"reference": "http://hl7.org/fhir/daf-encounter"
},
"section": [
{
"fhir_comments": [
" Included all sections identified in the Trifolia C-CDA on FHIR profile http://hl7.org/fhir/StructureDefinition/ccda-ccd-composition "
],
"title": "Allergies and Intolerances Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "48765-2",
"display": "Allergies and adverse reactions"
}
]
},
"text": {
"status": "generated",
"div": "<div>\n <table>\n <tr>\n <td>\n <b>Substance</b>\n </td>\n <td>\n <b>Overall Severity</b>\n </td>\n <td>\n <b>Reaction</b>\n </td>\n <td>\n <b>Reaction Severity</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Penicillin</td>\n <td>Moderate to Severe</td>\n <td>Nausea</td>\n <td>Mild</td>\n <td>Inactive</td>\n </tr>\n <tr>\n <td>Codeine</td>\n <td>Mild</td>\n <td>Wheezing</td>\n <td>Moderate</td>\n <td>Active</td>\n </tr>\n <tr>\n <td>Aspirin</td>\n <td>Mild</td>\n <td>Hives</td>\n <td>Mild to Moderate</td>\n <td>Active</td>\n </tr>\n </table>\n </div>"
},
"mode": "snapshot",
"_mode": {
"fhir_comments": [
" Composition.section.mode and orderedBy are optional in FHIR DSTU2, and not specified in the Trifolia CCD CCoF profile - should it be removed from the sample? "
]
},
"orderedBy": {
"coding": [
{
"system": "http://hl7.org/fhir/list-order",
"code": "event-date",
"display": "Sorted by Event Date"
}
]
}
},
{
"title": "Medication Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10160-0",
"display": "History of Medication Use"
}
]
},
"text": {
"status": "generated",
"div": "<div>\n <table>\n <tr>\n <td>\n <b>Medication</b>\n </td>\n <td>\n <b>Directions</b>\n </td>\n <td>\n <b>Start Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n <td>\n <b>Indications</b>\n </td>\n <td>\n <b>Fill Instructions</b>\n </td>\n </tr>\n <tr>\n <td>Proventil HFA</td>\n <td>Inhalant solution - 2 puffs QID PRN wheezing</td>\n <td>20151029</td>\n <td>Active</td>\n <td>Pneumonia</td>\n <td>Generic substitution allowed</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Problem Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11450-4",
"display": "Problem list"
}
]
},
"text": {
"status": "generated",
"div": "<div>\n <table>\n <tr>\n <td>\n <b>Problem Name</b>\n </td>\n <td>\n <b>Type</b>\n </td>\n <td>\n <b>Onset Date</b>\n </td>\n <td>\n <b>Abatement Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Pneumonia</td>\n <td>Diagnosis</td>\n <td>2015-10-29</td>\n <td>2016-01-15</td>\n <td>Complete</td>\n </tr>\n <tr>\n <td>Asthma</td>\n <td>Condition</td>\n <td>2000-02-15</td>\n <td/>\n <td>Active</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Procedures Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "47519-4",
"display": "History of procedures"
}
]
},
"text": {
"status": "generated",
"div": "<div>\n <table>\n <tr>\n <td>\n <b>Procedure Name</b>\n </td>\n <td>\n <b>Body Site</b>\n </td>\n <td>\n <b>Performer</b>\n </td>\n <td>\n <b>Date Performed</b>\n </td>\n </tr>\n <tr>\n <td>Lumbar Spinal Fusion</td>\n <td>Back Region</td>\n <td>Dr. S. Steen</td>\n <td>20150816</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Results Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "30954-2",
"display": "Relevant diagnostic tests and laboratory data"
}
]
},
"text": {
"status": "generated",
"div": "<div>\n <table>\n <tr>\n <td>\n <b>Result Type</b>\n </td>\n <td>\n <b>Quantity Value</b>\n </td>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Blood Chemistry - Folate in Red Blood Cells</td>\n <td>13.8 ug</td>\n <td>2015/02/01</td>\n <td>Preliminary</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Advance Directives Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "42348-3",
"display": "Advance directives"
}
]
},
"text": {
"status": "generated",
"div": "<div>\n <table>\n <tr>\n <td>\n <b>Name</b>\n </td>\n <td>\n <b>Applies Period</b>\n </td>\n </tr>\n <tr>\n <td>Resuscitation</td>\n <td>2015/01/01 - 2016/12/31</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Encounters Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "46240-8",
"display": "Encounters"
}
]
},
"text": {
"status": "generated",
"div": "<div>\n <table>\n <tr>\n <td>\n <b>Encounter</b>\n </td>\n <td>\n <b>Performer</b>\n </td>\n <td>\n <b>Location</b>\n </td>\n <td>\n <b>Date</b>\n </td>\n </tr>\n <tr>\n <td>Checkup Examination</td>\n <td>Dr. S. Steene</td>\n <td>Community Urgent Care Center</td>\n <td>2015/09/26</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Family History Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10157-6",
"display": "History of family member diseases"
}
]
},
"text": {
"status": "generated",
"div": "<div>\n <table>\n <tr>\n <td>\n <b>Relationship</b>\n </td>\n <td>\n <b>Diagnosis</b>\n </td>\n <td>\n <b>Age at Onset</b>\n </td>\n </tr>\n <tr>\n <td>Father</td>\n <td>Myocardial Infarction(cause of Death)</td>\n <td>57</td>\n </tr>\n <tr>\n <td>Father</td>\n <td>Diabetes</td>\n <td>40</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Functional Status Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "47420-5",
"display": "Functional status assessment"
}
]
},
"text": {
"status": "generated",
"div": "<div>\n <table>\n <tr>\n <td>\n <b>Functional or Cognitive Finding</b>\n </td>\n <td>\n <b>Observation</b>\n </td>\n <td>\n <b>Observation Date</b>\n </td>\n <td>\n <b>Condition Status</b>\n </td>\n </tr>\n <tr>\n <td>Ambulation (Dependent to Independent</td>\n <td>Independently able</td>\n <td>2010/03/11</td>\n <td>Active</td>\n </tr>\n <tr>\n <td>Finding of Functional Performance and Activity</td>\n <td>Dyspnea</td>\n <td>2008/02/16</td>\n <td>Active</td>\n </tr>\n <tr>\n <td>Cognitive Function Finding</td>\n <td>Memory Impairment</td>\n <td>2014/04/29</td>\n <td>Active</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Immunizations Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11369-6",
"display": "History of immunization"
}
]
},
"text": {
"status": "generated",
"div": "<div>\n <table>\n <tr>\n <td>\n <b>Vaccine</b>\n </td>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Influenza, Seasonal, IM</td>\n <td>1999/11/25</td>\n <td>Completed</td>\n </tr>\n <tr>\n <td>Tetanus and diptheria toxoids, IM</td>\n <td>1997/10/16</td>\n <td>Refused</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": " Nutrition Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "61144-2",
"display": "Diet and nutrition"
}
]
},
"text": {
"status": "generated",
"div": "<div>\n <table>\n <tr>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Nutritional Status</b>\n </td>\n <td>\n <b>Diet</b>\n </td>\n </tr>\n <tr>\n <td>2005/12/29</td>\n <td>Well nourished</td>\n <td>Low sodium diet, excessive carbohydrate</td>\n </tr>\n <tr>\n <td>2010/05/26</td>\n <td>Slight dehydration</td>\n <td>High protein, low fibre</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Mental Status Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10190-7",
"display": "Mental status"
}
]
},
"text": {
"status": "generated",
"div": "<div>\n <table>\n <tr>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Mental Status</b>\n </td>\n <td>\n <b>Support System</b>\n </td>\n </tr>\n <tr>\n <td>2005/06/21</td>\n <td>Good</td>\n <td>Not required</td>\n </tr>\n <tr>\n <td>2015/12/29</td>\n <td>Dimentia</td>\n <td>Daily Home Care</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Social History Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "29762-2",
"display": "Social history"
}
]
},
"text": {
"status": "generated",
"div": "<div>\n <table>\n <tr>\n <td>\n <b>Social History Element</b>\n </td>\n <td>\n <b>Description</b>\n </td>\n <td>\n <b>Effective Dates</b>\n </td>\n </tr>\n <tr>\n <td>Smoking</td>\n <td>1 pack per day</td>\n <td>2005/05/01 - 2010/02/28</td>\n </tr>\n <tr>\n <td>Alcohol Consumption</td>\n <td>2 Bottles of Wine per week</td>\n <td>2001/01/01</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Plan of Treatment Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "18776-5",
"display": "Plan of treatment"
}
]
},
"text": {
"status": "generated",
"div": "<div>\n <table>\n <tr>\n <td>\n <b>Planned Activity</b>\n </td>\n <td>\n <b>Period</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Colonoscopy</td>\n <td>2010/08/16 - 2010/08/16</td>\n <td>Completed</td>\n </tr>\n <tr>\n <td>Recommendation to Exercise</td>\n <td>2015/10/29</td>\n <td>Ongoing</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Payers Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "48768-6",
"display": "Payers"
}
]
},
"text": {
"status": "generated",
"div": "<div>\n <table>\n <tr>\n <td>\n <b>Payer Name</b>\n </td>\n <td>\n <b>Policy ID</b>\n </td>\n <td>\n <b>Policy Holder</b>\n </td>\n </tr>\n <tr>\n <td>United Healthcare</td>\n <td>12341</td>\n <td>Self</td>\n </tr>\n <tr>\n <td>Cigna</td>\n <td>53123</td>\n <td>Spouse</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Medical Equipment Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "46264-8",
"display": "Medical equipment"
}
]
},
"text": {
"status": "generated",
"div": "<div>\n <table>\n <tr>\n <td>\n <b>Supply/Device</b>\n </td>\n <td>\n <b>Date Supplied</b>\n </td>\n </tr>\n <tr>\n <td>Automatic Implantable cardioverter/defbrillator</td>\n <td>2008/11/16</td>\n </tr>\n <tr>\n <td>Wheelchair</td>\n <td>1999/12/01</td>\n </tr>\n </table>\n </div>"
}
},
{
"title": "Vital Signs Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "8716-3",
"display": "Vital signs"
}
]
},
"text": {
"status": "generated",
"div": "<div>\n <table>\n <tr>\n <td>\n <b>Vital Sign</b>\n </td>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Value</b>\n </td>\n </tr>\n <tr>\n <td>Height</td>\n <td>2011/01/13</td>\n <td>177 cm</td>\n </tr>\n <tr>\n <td>Weight</td>\n <td>2011/01/13</td>\n <td>86 kg</td>\n </tr>\n <tr>\n <td>Blood Pressure</td>\n <td>2011/01/13</td>\n <td>132/86 mmHg</td>\n </tr>\n </table>\n </div>"
}
}
]
}
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
© HL7.org 2011+. FHIR STU3 Candidate (v1.4.0-8139) generated on Thu, Mar 31, 2016 08:08+1100. QA Page
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