STU 1 Ballot

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


<Composition xmlns="http://hl7.org/fhir">
  <id value="ccda-diagnostic-imaging-composition-example"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2016-06-15T08:16:14Z"/>
    <profile
             value="http://hl7.org/fhir/StructureDefinition/ccda-diagnostic-imaging-composition"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">
      <p>Diagnostic Imaging Report document for Henry Jones</p>
      <p>Managed by Community Health and Hospitals</p>
    </div>
  </text>
  <extension
             url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-data-enterer-extension">
    <valueUri value="http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-informant-extension">
    <valueUri value="http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-information-recipient-extension">
    <valueUri value="http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-participant-extension">
    <valueUri value="http://fhirtest.uhn.ca/baseDstu3/RelatedPerson/117466"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-performer-extension">
    <valueUri value="http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-authorization-extension">
    <valueUri value="http://hl7.org/fhir/ccda/StructureDefinition/ccda-consent"/>
  </extension>
  <identifier>
    <system
            value="http://hl7.org/fhir/ccda/StructureDefinition/ccda-diagnostic-imaging-composition"/>
    <value value="1"/>
  </identifier>
  <date value="2016-03-22T09:10:14Z"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="18748-4"/>
      <display value="Diagnostic Imaging Report"/>
    </coding>
  </type>
  <title value="Diagnostic Imaging Report"/>
  <status value="preliminary"/>
  <confidentiality value="N"/>
<!--   Patient Resource  -->
  <subject>
    <reference value="http://fhirtest.uhn.ca/baseDstu3/Patient/117467"/>
    <display value="Henry Jones"/>
  </subject>
<!--   Practitioner Resource  -->
  <author>
    <reference value="http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"/>
    <display value="Adam Everyman, MD"/>
  </author>
  <attester>
    <mode value="legal"/>
    <time value="2012-01-04T09:10:14Z"/>
    <party>
      <reference value="http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"/>
      <display value="Adam Everyman, MD"/>
    </party>
  </attester>
<!--   Organization Resource  -->
  <custodian>
    <reference value="http://fhirtest.uhn.ca/baseDstu3/Organization/117471"/>
    <display value="Community Health and Hospitals"/>
  </custodian>
  <event>
    <code>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="73761001"/>
        <display value="Colonoscopy"/>
      </coding>
    </code>
    <period>
      <start value="2015-11-18"/>
      <end value="2015-12-12"/>
    </period>
  </event>
<!--   Encounter Resource  -->
  <encounter>
    <reference value="http://fhirtest.uhn.ca/baseDstu3/Encounter/117630"/>
  </encounter>
<!--   Findings Section Narrative  -->
  <section>
    <title value="Findings Section"/>
    <code>
      <coding>
        <system value="urn:oid:1.2.840.10008.2.16.4"/>
        <code value="121070"/>
        <display value="Findings"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>The cardiomediastinum is within normal limits. The trachea is midline. 
                    The previously described opacity at the medial right lung base has cleared. 
                    There are no new infiltrates. There is a new round density at the left hilus, 
                    superiorly (diameter about 45mm). A CT scan is recommended for further evaluation. 
                    The pleural spaces are clear. The visualized musculoskeletal structures and the
                    upper abdomen are stable and unremarkable.</p>
      </div>
    </text>
  </section>
<!--   DICOM Object Catalog Section Narrative  -->
  <section>
    <title value="DICOM Object Catalog Section"/>
    <code>
      <coding>
        <system value="urn:oid:1.2.840.10008.2.16.4"/>
        <code value="121181"/>
        <display value="DICOM Object Catalog"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>Computed Radiography Image Storage</p>
      </div>
    </text>
  </section>
<!--   Indications for Procedure Section Narrative  -->
  <section>
    <title value="Indications for Procedure Section"/>
    <code>
      <coding>
        <system value="urn:oid:1.2.840.10008.2.16.4"/>
        <code value="121109"/>
        <display value="Indications for Procedure"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>Suspected lung tumor</p>
      </div>
    </text>
  </section>
</Composition>