This page is part of the C-CDA on FHIR Implementation Guide (v1.6.0: STU 1 Ballot 1) based on FHIR v1.6.0. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

{
  "resourceType" : "Composition",
  "id" : "ccda-ccd-composition-example",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2016-06-15T08:16:14Z",
    "profile" : [
      "http://hl7.org/fhir/StructureDefinition/ccda-ccd-composition"
    }
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
      <p>Continuity of Care document for Henry Jones</p>
      <p>Managed by Community Health and Hospitals</p>
    </div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-data-enterer-extension",
      "valueUri" : "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"
    },
    {
      "url" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-informant-extension",
      "valueUri" : "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"
    },
    {
      "url" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-information-recipient-extension",
      "valueUri" : "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"
    },
    {
      "url" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-participant-extension",
      "valueUri" : "http://fhirtest.uhn.ca/baseDstu3/RelatedPerson/117466"
    },
    {
      "url" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-performer-extension",
      "valueUri" : "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"
    },
    {
      "url" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-authorization-extension",
      "valueUri" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-consent"
    }
  },
  "identifier" : {
    "system" : "http://hl7.org/fhir/ccda/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://fhirtest.uhn.ca/baseDstu3/Patient/117467",
    "display" : "Henry Jones"
  },
  "author" : [
    {
      "reference" : "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497",
      "display" : "Adam Everyman, MD"
    }
  },
  "attester" : [
    {
      "mode" : [
        "legal"
      },
      "time" : "2012-01-04T09:10:14Z",
      "party" : {
        "reference" : "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497",
        "display" : "Adam Everyman, MD"
      }
    }
  },
  "custodian" : {
    "reference" : "http://fhirtest.uhn.ca/baseDstu3/Organization/117471",
    "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://fhirtest.uhn.ca/baseDstu3/Encounter/117630"
  },
  "section" : [
    {
      "title" : "Allergies and Intolerances Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "48765-2",
            "display" : "Allergies and adverse reactions"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Substance</b>
            </td>
            <td>
              <b>Overall Severity</b>
            </td>
            <td>
              <b>Reaction</b>
            </td>
            <td>
              <b>Reaction Severity</b>
            </td>
            <td>
              <b>Status</b>
            </td>
          </tr>
          <tr>
            <td>Cashew Nut</td>
            <td>Severe</td>
            <td>Anaphylactic reaction</td>
            <td>Mild</td>
            <td>Active</td>
          </tr>
        </table>
      </div>"
      },
      "mode" : "snapshot",
      "orderedBy" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/list-order",
            "code" : "event-date",
            "display" : "Sorted by Event Date"
          }
        }
      },
      "entry" : [
        {
          "reference" : "http://fhirtest.uhn.ca/baseDstu3/AllergyIntolerance/117632"
        }
      }
    },
    {
      "title" : "Medication Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "10160-0",
            "display" : "History of Medication Use"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Medication</b>
            </td>
            <td>
              <b>Directions</b>
            </td>
            <td>
              <b>Start Date</b>
            </td>
            <td>
              <b>Status</b>
            </td>
            <td>
              <b>Indications</b>
            </td>
            <td>
              <b>Fill Instructions</b>
            </td>
          </tr>
          <tr>
            <td>Amoxicillin</td>
            <td>Amoxicillin Powder, for Suspension 250mg/5ml</td>
            <td>20160401</td>
            <td>Active</td>
            <td>Pneumonia</td>
            <td>Generic substitution allowed</td>
          </tr>
        </table>
      </div>"
      },
      "entry" : [
        {
          "reference" : "http://fhirtest.uhn.ca/baseDstu3/Medication/117679"
        }
      }
    },
    {
      "title" : "Problem Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "11450-4",
            "display" : "Problem list"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Problem Name</b>
            </td>
            <td>
              <b>Type</b>
            </td>
            <td>
              <b>Onset Date</b>
            </td>
            <td>
              <b>Abatement Date</b>
            </td>
            <td>
              <b>Status</b>
            </td>
          </tr>
          <tr>
            <td>Fever</td>
            <td>Condition</td>
            <td>2016-04-01</td>
            <td>2016-04-14</td>
            <td>Complete</td>
          </tr>
        </table>
      </div>"
      },
      "entry" : [
        {
          "reference" : "http://fhirtest.uhn.ca/baseDstu3/Condition/117648"
        }
      }
    },
    {
      "title" : "Procedures Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "47519-4",
            "display" : "History of procedures"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Procedure Name</b>
            </td>
            <td>
              <b>Body Site</b>
            </td>
            <td>
              <b>Performer</b>
            </td>
            <td>
              <b>Date Performed</b>
            </td>
            <td>
              <b>Reason</b>
            </td>
          </tr>
          <tr>
            <td>Appendectomy (Procedure)</td>
            <td>Abdomen</td>
            <td>Dr. Adam Everyman</td>
            <td>20160405</td>
            <td>Generalized abdominal pain 24 hours. Localized in RIF with rebound and guarding</td>
          </tr>
        </table>
      </div>"
      },
      "entry" : [
        {
          "reference" : "http://fhirtest.uhn.ca/baseDstu3/Procedure/117687"
        }
      }
    },
    {
      "title" : "Results Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "30954-2",
            "display" : "Relevant diagnostic tests and laboratory data"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Result Type</b>
            </td>
            <td>
              <b>Quantity Value</b>
            </td>
            <td>
              <b>Date</b>
            </td>
            <td>
              <b>Status</b>
            </td>
          </tr>
          <tr>
            <td>Glucose [Moles/volume] in Blood</td>
            <td>6.3 mmol/l</td>
            <td>2016/04/01</td>
            <td>Final</td>
          </tr>
        </table>
      </div>"
      },
      "entry" : [
        {
          "reference" : "http://fhirtest.uhn.ca/baseDstu3/Observation/117685"
        }
      }
    },
    {
      "title" : "Advance Directives Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "42348-3",
            "display" : "Advance directives"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Name</b>
            </td>
            <td>
              <b>Applies Period</b>
            </td>
          </tr>
          <tr>
            <td>Resuscitation</td>
            <td>2015/01/01 - 2016/12/31</td>
          </tr>
        </table>
      </div>"
      }
    },
    {
      "title" : "Encounters Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "46240-8",
            "display" : "Encounters"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Encounter</b>
            </td>
            <td>
              <b>Performer</b>
            </td>
            <td>
              <b>Location</b>
            </td>
            <td>
              <b>Date</b>
            </td>
          </tr>
          <tr>
            <td>Checkup Examination</td>
            <td>Dr. S. Steene</td>
            <td>Community Urgent Care Center</td>
            <td>2015/09/26</td>
          </tr>
        </table>
      </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 xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Relationship</b>
            </td>
            <td>
              <b>Diagnosis</b>
            </td>
            <td>
              <b>Age at Onset</b>
            </td>
          </tr>
          <tr>
            <td>Father</td>
            <td>Myocardial Infarction(cause of Death)</td>
            <td>57</td>
          </tr>
          <tr>
            <td>Father</td>
            <td>Diabetes</td>
            <td>40</td>
          </tr>
        </table>
      </div>"
      },
      "entry" : [
        {
          "reference" : "http://fhirtest.uhn.ca/baseDstu3/FamilyMemberHistory/117652"
        }
      }
    },
    {
      "title" : "Functional Status Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "47420-5",
            "display" : "Functional status assessment"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Functional or Cognitive Finding</b>
            </td>
            <td>
              <b>Observation</b>
            </td>
            <td>
              <b>Observation Date</b>
            </td>
            <td>
              <b>Condition Status</b>
            </td>
          </tr>
          <tr>
            <td>Ambulation (Dependent to Independent</td>
            <td>Independently able</td>
            <td>2010/03/11</td>
            <td>Active</td>
          </tr>
          <tr>
            <td>Finding of Functional Performance and Activity</td>
            <td>Dyspnea</td>
            <td>2008/02/16</td>
            <td>Active</td>
          </tr>
          <tr>
            <td>Cognitive Function Finding</td>
            <td>Memory Impairment</td>
            <td>2014/04/29</td>
            <td>Active</td>
          </tr>
        </table>
      </div>"
      }
    },
    {
      "title" : "Immunizations Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "11369-6",
            "display" : "History of immunization"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Vaccine</b>
            </td>
            <td>
              <b>Date</b>
            </td>
            <td>
              <b>Status</b>
            </td>
          </tr>
          <tr>
            <td>Fluvax (Influenza)</td>
            <td>2016-04-05</td>
            <td>Completed</td>
          </tr>
        </table>
      </div>"
      },
      "entry" : [
        {
          "reference" : "http://fhirtest.uhn.ca/baseDstu3/Immunization/117678"
        }
      }
    },
    {
      "title" : " Nutrition Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "61144-2",
            "display" : "Diet and nutrition"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Date</b>
            </td>
            <td>
              <b>Nutritional Status</b>
            </td>
            <td>
              <b>Diet</b>
            </td>
          </tr>
          <tr>
            <td>2005/12/29</td>
            <td>Well nourished</td>
            <td>Low sodium diet, excessive carbohydrate</td>
          </tr>
          <tr>
            <td>2010/05/26</td>
            <td>Slight dehydration</td>
            <td>High protein, low fibre</td>
          </tr>
        </table>
      </div>"
      }
    },
    {
      "title" : "Mental Status Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "10190-7",
            "display" : "Mental status"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Date</b>
            </td>
            <td>
              <b>Mental Status</b>
            </td>
            <td>
              <b>Support System</b>
            </td>
          </tr>
          <tr>
            <td>2005/06/21</td>
            <td>Good</td>
            <td>Not required</td>
          </tr>
          <tr>
            <td>2015/12/29</td>
            <td>Dimentia</td>
            <td>Daily Home Care</td>
          </tr>
        </table>
      </div>"
      }
    },
    {
      "title" : "Social History Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "29762-2",
            "display" : "Social history"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Social History Element</b>
            </td>
            <td>
              <b>Description</b>
            </td>
            <td>
              <b>Effective Dates</b>
            </td>
          </tr>
          <tr>
            <td>Smoking</td>
            <td>1 pack tobacco per day</td>
            <td>2005/05/01 - 2010/02/28</td>
          </tr>
        </table>
      </div>"
      },
      "entry" : [
        {
          "reference" : "http://fhirtest.uhn.ca/baseDstu3/Observation/117688"
        }
      }
    },
    {
      "title" : "Plan of Treatment Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "18776-5",
            "display" : "Plan of treatment"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Planned Activity</b>
            </td>
            <td>
              <b>Period</b>
            </td>
            <td>
              <b>Status</b>
            </td>
          </tr>
          <tr>
            <td>Colonoscopy</td>
            <td>2010/08/16 - 2010/08/16</td>
            <td>Completed</td>
          </tr>
          <tr>
            <td>Recommendation to Exercise</td>
            <td>2015/10/29</td>
            <td>Ongoing</td>
          </tr>
        </table>
      </div>"
      }
    },
    {
      "title" : "Payers Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "48768-6",
            "display" : "Payers"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Payer Name</b>
            </td>
            <td>
              <b>Policy ID</b>
            </td>
            <td>
              <b>Policy Holder</b>
            </td>
          </tr>
          <tr>
            <td>United Healthcare</td>
            <td>12341</td>
            <td>Self</td>
          </tr>
          <tr>
            <td>Cigna</td>
            <td>53123</td>
            <td>Spouse</td>
          </tr>
        </table>
      </div>"
      }
    },
    {
      "title" : "Medical Equipment Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "46264-8",
            "display" : "Medical equipment"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Supply/Device</b>
            </td>
            <td>
              <b>Date Supplied</b>
            </td>
          </tr>
          <tr>
            <td>Automatic Implantable cardioverter/defbrillator</td>
            <td>2008/11/16</td>
          </tr>
          <tr>
            <td>Wheelchair</td>
            <td>1999/12/01</td>
          </tr>
        </table>
      </div>"
      }
    },
    {
      "title" : "Vital Signs Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "8716-3",
            "display" : "Vital signs"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tr>
            <td>
              <b>Vital Sign</b>
            </td>
            <td>
              <b>Date</b>
            </td>
            <td>
              <b>Value</b>
            </td>
          </tr>
          <tr>
            <td>Temperature</td>
            <td>2016/04/05</td>
            <td>39 Degrees Celcius</td>
          </tr>
        </table>
      </div>"
      },
      "entry" : [
        {
          "reference" : "http://fhirtest.uhn.ca/baseDstu3/Observation/117689"
        }
      }
    }
  }
}