C-CDA on FHIR
1.2.0-ballot - CI Build
C-CDA on FHIR
1.2.0-ballot - CI Build
This page is part of the C-CDA on FHIR Implementation Guide (v1.2.0-ballot: STU 1 Ballot 4) based on FHIR R4. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions 
@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <https://loinc.org/rdf/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix sct: <http://snomed.info/id/> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:Composition ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "Operative-Note-Example"] ; #
fhir:meta [
fhir:versionId [ fhir:v "4" ] ;
fhir:lastUpdated [ fhir:v "2020-08-12T21:30:19.501+00:00"^^xsd:dateTime ] ;
fhir:source [ fhir:v "#csn482LCsnDWyxbW"^^xsd:anyURI ] ;
( fhir:profile [
fhir:v "http://hl7.org/fhir/us/ccda/StructureDefinition/Operative-Note"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/ccda/StructureDefinition/Operative-Note> ] )
] ; #
fhir:language [ fhir:v "en-US"] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\">\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Document Id</span>\n </td>\n <td class=\"td_header_role_value\">12345</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Document Created:</span>\n </td>\n <td class=\"td_header_role_value\">June 15, 2016, 16:14, PST </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Care Provision</span>\n </td>\n <td class=\"td_header_role_value\">Operation Note for Amy\n Shaw</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Performer </span>\n </td>\n <td class=\"td_header_role_value\">Ronald Boone, MD</td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Author</span>\n </td>\n <td class=\"td_header_role_value\">Ronald Boone, MD</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1003 Healthcare Drive\n \n <br/>Amherst MA 01002, US \n <br/>Tel: +1(555)555-1003\n \n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Encounter Id</span>\n </td>\n <td class=\"td_header_role_value\">9937012\n 2.16.840.1.113883.19</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Event Type</span>\n </td>\n <td class=\"td_header_role_value\">Surgery</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Event Date</span>\n </td>\n <td class=\"td_header_role_value\"> From June 15, 2016, 16:20 to\n June 15, 2016, 18:20 </td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Encounter Location</span>\n </td>\n <td class=\"td_header_role_value\">Perioperative Department at\n Community Health and Hospitals</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Responsible party</span>\n </td>\n <td class=\"td_header_role_value\">Ronald Boone, MD</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1003 Healthcare Drive\n \n <br/>Amherst MA 01002, US \n <br/>Tel: +1(555)555-1003\n \n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Assigned entity</span>\n </td>\n <td class=\"td_header_role_value\">Community Health and Hospitals\n \n <br/>\n </td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Emergency contact</span>\n </td>\n <td class=\"td_header_role_value\">Michael Shaw \n <br/>\n <br/>\n </td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">49 Meadow St \n <br/>Amherst MA\n 01003, US \n <br/>Tel: (555)555-1212 \n <br/>\n </td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Care giver</span>\n </td>\n <td class=\"td_header_role_value\">Mrs. Lillian White \n <br/>\n </td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">49 Meadow St \n <br/>Amherst MA\n 01003, US \n <br/>Tel: (555)555-1215 \n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Entered by</span>\n </td>\n <td class=\"td_header_role_value\">Sally Jones</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1003 Healthcare Drive\n \n <br/>Amherst MA 01002, US \n <br/>Tel: +1(555)555-1003\n \n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Signed </span>\n </td>\n <td class=\"td_header_role_value\">Ronald Boone at June 15, 2016\n </td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1003 Healthcare Drive\n \n <br/>Amherst MA 01002, US \n <br/>Tel: +1(555)555-1003\n \n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Informant</span>\n </td>\n <td class=\"td_header_role_value\">Henry Vincent, CPh</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1007 Pharmacy Drive\n \n <br/>Portland, OR 99123, US \n <br/>Tel: +1(555)555-1215\n \n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Information recipient:</span>\n </td>\n <td class=\"td_header_role_value\">Primary Physician, MD</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1005 St. Clair Avenue\n \n <br/>Amherst MA 01002, US \n <br/>Tel: +1(555)555-1666\n \n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Legal authenticator</span>\n </td>\n <td class=\"td_header_role_value\">Ronald Boone, MD signed at June\n 15, 2016 </td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1003 Healthcare Drive\n \n <br/>Amherst MA 01002, US \n <br/>Tel: +1(555)555-1003\n \n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Document maintained by</span>\n </td>\n <td class=\"td_header_role_value\">Community Health and\n Hospitals</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1003 Healthcare Drive\n \n <br/>Amherst MA 01002, US \n <br/>Tel: +1(555)555-1003\n \n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n </div>"
] ; #
fhir:identifier [
fhir:system [ fhir:v "urn:ietf:rfc:3986"^^xsd:anyURI ] ;
fhir:value [ fhir:v "urn:uuid:75a12dcd-f85d-4c7f-b1de-38a1a2b7498f" ]
] ; #
fhir:status [ fhir:v "preliminary"] ; #
fhir:type [
( fhir:coding [
a loinc:11504-8 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "11504-8" ] ;
fhir:display [ fhir:v "Surgical operation note" ] ] )
] ; #
fhir:subject [
fhir:reference [ fhir:v "Patient/example" ] ;
fhir:display [ fhir:v "Amy V. Shaw" ]
] ; #
fhir:date [ fhir:v "2016-06-15T09:10:14Z"^^xsd:dateTime] ; #
fhir:author ( [
fhir:reference [ fhir:v "PractitionerRole/ccda-practitionerrole-example" ] ;
fhir:display [ fhir:v "Ronald Bone, MD" ]
] ) ; #
fhir:title [ fhir:v "Operative Note"] ; #
fhir:attester ( [
fhir:mode [ fhir:v "legal" ] ;
fhir:time [ fhir:v "2016-06-15T09:10:14Z"^^xsd:dateTime ] ;
fhir:party [
fhir:reference [ fhir:v "PractitionerRole/ccda-practitionerrole-example" ] ;
fhir:display [ fhir:v "Ronald Boone, MD" ] ]
] ) ; #
fhir:custodian [
fhir:reference [ fhir:v "Organization/organization-1" ] ;
fhir:display [ fhir:v "Community Health and Hospitals" ]
] ; #
fhir:event ( [
( fhir:code [
( fhir:coding [
a sct:73761001 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "73761001" ] ;
fhir:display [ fhir:v "Colonoscopy" ] ] ) ] ) ;
fhir:period [
fhir:start [ fhir:v "2016-06-15"^^xsd:date ] ;
fhir:end [ fhir:v "2016-06-15"^^xsd:date ] ]
] ) ; #
fhir:section ( [
fhir:title [ fhir:v "Anesthesia Section" ] ;
fhir:code [
( fhir:coding [
a loinc:59774-0 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "59774-0" ] ;
fhir:display [ fhir:v "Anesthesia" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Conscious sedation with propofol 200 mg IV</p>\n </div>" ]
] [
fhir:title [ fhir:v "Complications Section" ] ;
fhir:code [
( fhir:coding [
a loinc:55109-3 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "55109-3" ] ;
fhir:display [ fhir:v "Complications Document" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Asthmatic symptoms while under general anesthesia.</p>\n </div>" ] ;
( fhir:entry [
fhir:reference [ fhir:v "Condition/condition-problem" ] ] )
] [
fhir:title [ fhir:v "Preoperative Diagnosis Section" ] ;
fhir:code [
( fhir:coding [
a loinc:10219-4 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "10219-4" ] ;
fhir:display [ fhir:v "Surgical operation note preoperative diagnosis Narrative" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Appendicitis</p>\n </div>" ]
] [
fhir:title [ fhir:v "Operative Note Surgical Procedure Section" ] ;
fhir:code [
( fhir:coding [
a loinc:10223-6 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "10223-6" ] ;
fhir:display [ fhir:v "Surgical operation note surgical procedure Narrative" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Laparoscopic Appendectomy</p>\n </div>" ]
] [
fhir:title [ fhir:v "Planned Procedure Section" ] ;
fhir:code [
( fhir:coding [
a loinc:59772-4 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "59772-4" ] ;
fhir:display [ fhir:v "Planned procedure" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Colonoscopy</p>\n </div>" ]
] [
fhir:title [ fhir:v "Procedure Indications Section" ] ;
fhir:code [
( fhir:coding [
a loinc:59768-2 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "59768-2" ] ;
fhir:display [ fhir:v "Procedure indications [Interpretation] Narrative" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>The procedure is performed for screening in a low risk\n individual.</p>\n </div>" ]
] [
fhir:title [ fhir:v "Procedure Description Section" ] ;
fhir:code [
( fhir:coding [
a loinc:29554-3 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "29554-3" ] ;
fhir:display [ fhir:v "Procedure Narrative" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>The patient was brought to the operating room, placed in the supine\n position, and general anesthesia was induced. A detailed technical\n narrative of a laparoscopic appendectomy from initial incision to\n placement of any dressings follows. </p>\n </div>" ]
] [
fhir:title [ fhir:v "Procedure Estimated Blood Loss Section" ] ;
fhir:code [
( fhir:coding [
a loinc:59770-8 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "59770-8" ] ;
fhir:display [ fhir:v "Procedure estimated blood loss Narrative" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Minimal</p>\n </div>" ]
] [
fhir:title [ fhir:v "Procedure Findings Section" ] ;
fhir:code [
( fhir:coding [
a loinc:59776-5 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "59776-5" ] ;
fhir:display [ fhir:v "Procedure findings Narrative" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>A 6 mm sessile polyp was found in the ascending colon and removed by\n snare, no cautery. Bleeding was controlled. Moderate diverticulosis\n and hemorrhoids were incidentally noted.</p>\n </div>" ] ;
( fhir:entry [
fhir:reference [ fhir:v "Condition/condition-problem" ] ] )
] [
fhir:title [ fhir:v "Procedure Specimens Taken Section" ] ;
fhir:code [
( fhir:coding [
a loinc:59773-2 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "59773-2" ] ;
fhir:display [ fhir:v "Procedure specimens taken Narrative" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Ascending colon polyp</p>\n </div>" ]
] [
fhir:title [ fhir:v "Operative Note Fluids Section" ] ;
fhir:code [
( fhir:coding [
a loinc:10216-0 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "10216-0" ] ;
fhir:display [ fhir:v "Operative Note Fluids" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>250 ML Ringers Lactate</p>\n </div>" ]
] [
fhir:title [ fhir:v "Surgical Drains Section" ] ;
fhir:code [
( fhir:coding [
a loinc:11537-8 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "11537-8" ] ;
fhir:display [ fhir:v "Surgical Drains" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Penrose drain placed</p>\n </div>" ]
] [
fhir:title [ fhir:v "Procedure Implants Section" ] ;
fhir:code [
( fhir:coding [
a loinc:59771-6 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "59771-6" ] ;
fhir:display [ fhir:v "Procedure implants Narrative" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>No implants were placed.</p>\n </div>" ]
] [
fhir:title [ fhir:v "Procedure Disposition Section" ] ;
fhir:code [
( fhir:coding [
a loinc:59775-7 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "59775-7" ] ;
fhir:display [ fhir:v "Procedure disposition Narrative" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>The patient was taken to the Endoscopy Recovery Unit in stable\n condition.</p>\n </div>" ]
] [
fhir:title [ fhir:v "Postoperative Diagnosis Section" ] ;
fhir:code [
( fhir:coding [
a loinc:10218-6 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "10218-6" ] ;
fhir:display [ fhir:v "Surgical operation note postoperative diagnosis Narrative" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Appendicitis with periappendiceal abscess</p>\n </div>" ]
] [
fhir:title [ fhir:v "Plan of Treatment Section" ] ;
fhir:code [
( fhir:coding [
a loinc:18776-5 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "18776-5" ] ;
fhir:display [ fhir:v "Plan of care note" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\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>2016/09/17 - 2010/09/17</td>\n <td>Planned</td>\n </tr>\n <tr>\n <td>Recommendation to Exercise</td>\n <td>2016/06/25</td>\n <td>Ongoing</td>\n </tr>\n </table>\n </div>" ]
] ) . #
# <section>
# <title value="Allergies and Intolerances Section"/>
# <code>
# <coding>
# <system value="http://loinc.org"/>
# <code value="48765-2"/>
# <display value="Allergies and adverse reactions Document"/>
# </coding>
# </code>
# <text>
# <status value="generated"/>
# <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>
# </text>
# <entry>
# <reference value="AllergyIntolerance/allergy-intolerance"/>
# </entry>
# </section>
# ,
# <entry>
# <reference value="Condition/condition-problem"/>
# </entry>
#
IG © 2020+ HL7 Structured Documents Working Group. Package hl7.fhir.us.ccda#1.2.0-ballot based on FHIR 4.0.1. Generated 2023-03-27
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