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

C-CDA on FHIR: ccda-progress-note-composition-example

Formats: XML Example or JSON Example or Turtle Example.

The narrative from the above example:

Progress Note

Progress Note document for Henry Jones

Managed by Community Health and Hospitals

Subject Details

Allergies and Intolerances Section

Substance Overall Severity Reaction Reaction Severity Status
Cashew Nut Severe Anaphylactic reaction Mild Active

Assessment Section

Obesity.

Uncontrolled brittle Type II diabetic.

Shortness of breath, mild wheezing.

Pressure ulder on left knee.

Assessment and Plan Section

Recurrent GI bleed of unknown etiology; hypotension perhaps secondary to this but as likely secondary to polypharmacy

Acute on chronic anemia secondary to #1.

Azotemia, acute renal failure with volume loss secondary tom#1.

Hyperkalemia secondary to #3 and on ACE and K+ supplement.

Other chronic diagnoses as noted above, currently stable.

Chief Complaint Section

Dark Stools

Instructions Section

Patient may have low grade fever, mild joint pain and injection area tenderness.

Interventions Section

Planned Intervention Status Date
Elevate head of bed active September 2, 2015
Oxygen administration by nasal cannula active September 1, 2015
pulse oximetry monitoring active September 3, 2015

Nutrition Section

Date Nutritional Status Diet
2005/12/29 Well nourished Low sodium diet, excessive carbohydrate
2010/05/26 Slight dehydration High protein, low fibre

Physical Exam Section

HEENT: All normal to examination.

>HEART: RRR, no murmur.

THORAX & LUNGS: Clear without rhonchi or wheeze.

ABDOMEN: Marked distension and tenderness, slightly obese, pos bowelsounds.

BACK: Normal to inspection and palpation, without tenderness; no presacral edema.

EXTREMITIES: Doughy edema bilaterally, chronic stasis changes, no asymmetrical swelling.

Objective Section

Chest: clear to ausc. No rales, normal breath sounds

Heart: RR, PMI in normal location and no heave or evidence ofcardiomegaly,normal heart sounds, no murm or gallop

Subjective Section

Complaints of rectal bleeding, fatigue and a change in bowel patterns.

Has several days of constipation alternating with diarrhea.

Review of Systems Section

Patient denies recent history of fever or malaise. Positive for weakness and shortness of breath. Several episodes of abdominal tenderness. No recent headaches. Positive for osteoarthritis in hips, knees and hands.

Medication Section

Medication Directions Start Date Status Indications Fill Instructions
Amoxicillin Amoxicillin Powder, for Suspension 250mg/5ml 20160401 Active Pneumonia Generic substitution allowed

Plan of Treatment Section

Planned Activity Period Status
Colonoscopy 2010/08/16 - 2010/08/16 Completed
Recommendation to Exercise 2015/10/29 Ongoing

Problem Section

Problem Name Type Onset Date Abatement Date Status
Fever Condition 2016-04-01 2016-04-14 Complete

Results Section

Result Type Quantity Value Date Status
Glucose [Moles/volume] in Blood 6.3 mmol/l 2016/04/01 Final

Vital Signs Section

Vital Sign Date Value
Temperature 2016/04/05 39 Degrees Celcius

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.