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 
<Composition xmlns="http://hl7.org/fhir">
<id value="Transfer-Summary-Example"/>
<meta>
<versionId value="4"/>
<lastUpdated value="2020-08-12T21:30:12.324+00:00"/>
<source value="#csn482LCsnDWyxbW"/>
<profile
value="http://hl7.org/fhir/us/ccda/StructureDefinition/Transfer-Summary"/>
</meta>
<language value="en-US"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US">
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Document Id</span>
</td>
<td class="td_header_role_value">12345</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Document Created:</span>
</td>
<td class="td_header_role_value">June 15, 2016, 16:14, PST </td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Care Provision</span>
</td>
<td class="td_header_role_value">Transfer Summary for Amy
Shaw</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Performer </span>
</td>
<td class="td_header_role_value">Ronald Boone, MD</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Author</span>
</td>
<td class="td_header_role_value">Ronald Boone, MD</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Encounter Id</span>
</td>
<td class="td_header_role_value">9937012
2.16.840.1.113883.19</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Event Type</span>
</td>
<td class="td_header_role_value">Transfer Summary</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Event Date</span>
</td>
<td class="td_header_role_value"> From June 15, 2016, 16:20 to
June 15, 2016, 18:20 </td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Encounter Location</span>
</td>
<td class="td_header_role_value">Inpatient Care at Community
Health and Hospitals</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Responsible party</span>
</td>
<td class="td_header_role_value">Ronald Boone, MD</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Assigned entity</span>
</td>
<td class="td_header_role_value">Community Health and Hospitals
<br/>
</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Emergency contact</span>
</td>
<td class="td_header_role_value">Michael Shaw
<br/>
<br/>
</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">49 Meadow St
<br/>Amherst MA
01003, US
<br/>Tel: (555)555-1212
<br/>
</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Care giver</span>
</td>
<td class="td_header_role_value">Mrs. Lillian White
<br/>
</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">49 Meadow St
<br/>Amherst MA
01003, US
<br/>Tel: (555)555-1215
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Entered by</span>
</td>
<td class="td_header_role_value">Sally Jones</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Signed </span>
</td>
<td class="td_header_role_value">Ronald Boone at June 15, 2016
</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Informant</span>
</td>
<td class="td_header_role_value">Henry Vincent, CPh</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1007 Pharmacy Drive
<br/>Portland, OR 99123, US
<br/>Tel: +1(555)555-1215
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Information recipient:</span>
</td>
<td class="td_header_role_value">Primary Physician, MD</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1005 St. Clair Avenue
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1666
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Legal authenticator</span>
</td>
<td class="td_header_role_value">Ronald Boone, MD signed at June
15, 2016 </td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Document maintained by</span>
</td>
<td class="td_header_role_value">Community Health and
Hospitals</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
</div>
</text>
<identifier>
<system value="urn:ietf:rfc:3986"/>
<value value="urn:uuid:e4edfcc8-bc7a-4c79-a844-42c83f209ddc"/>
</identifier>
<status value="preliminary"/>
<type>
<coding>
<system value="http://loinc.org"/>
<code value="18761-7"/>
<display value="Transfer summary note"/>
</coding>
</type>
<subject>
<reference value="Patient/example"/>
<display value="Amy V. Shaw"/>
</subject>
<date value="2016-06-15T09:10:14Z"/>
<author>
<reference value="PractitionerRole/ccda-practitionerrole-example"/>
<display value="Ronald Bone, MD"/>
</author>
<title value="Transfer Summary"/>
<custodian>
<reference value="Organization/organization-1"/>
<display value="Acme Labs"/>
</custodian>
<event>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="73761001"/>
<display value="Colonoscopy"/>
</coding>
</code>
<period>
<start value="2016-06-15"/>
<end value="2016-06-15"/>
</period>
</event>
<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>
<section>
<title value="Advance Directives Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="42348-3"/>
<display value="Advance directives"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
</section>
<section>
<title value="Assessment Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="51848-0"/>
<display value="Evaluation note"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Obesity.</p>
<p>Uncontrolled brittle Type II diabetic.</p>
<p>Shortness of breath, mild wheezing.</p>
<p>Pressure ulder on left knee.</p>
</div>
</text>
</section>
<section>
<title value="Assessment and Plan Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="51847-2"/>
<display value="Evaluation + Plan note"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Recurrent GI bleed of unknown etiology; hypotension perhaps secondary
to this but as likely secondary to polypharmacy</p>
<p>Acute on chronic anemia secondary to #1.</p>
<p>Azotemia, acute renal failure with volume loss secondary tom#1.</p>
<p>Hyperkalemia secondary to #3 and on ACE and K+ supplement.</p>
<p>Other chronic diagnoses as noted above, currently stable.</p>
</div>
</text>
</section>
<!-- <section>
<title value="Chief Complaint and Reason for Visit Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="46239-0"/>
<display value="Chief complaint+Reason for visit Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div
xmlns="http://www.w3.org/1999/xhtml">
<p>Cramping, bloating, and constipation.</p>
</div>
</text>
</section> -->
<section>
<title value="Admission Diagnosis Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="46241-6"/>
<display value="Hospital admission diagnosis Narrative - Reported"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Appendicitis</p>
</div>
</text>
</section>
<section>
<title value="Admission Medications Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="42346-7"/>
<display value="Medications on admission (narrative)"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>Pepcid Complete (MAGNESIUM HYDROXIDE0</td>
<td>Chew one tablet completely and swallow as needed </td>
<td>20160615</td>
<td>Active</td>
<td>Bloating</td>
<td>Generic substitution allowed</td>
</tr>
</table>
</div>
</text>
</section>
<section>
<title value="Encounters Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="46240-8"/>
<display
value="History of Hospitalizations+Outpatient visits Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
</section>
<section>
<title value="Past Medical History Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11348-0"/>
<display value="History of Past illness Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
<entry>
<reference value="Condition/condition-problem"/>
</entry>
</section>
<section>
<title value="History of Present Illness Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10164-2"/>
<display value="History of Present illness Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>This patient was only recently discharged for a recurrent GI bleed as
described below. </p>
<p>He presented to the ER today c/o a dark stool yesterday but a normal
brown stool today. On exam he was hypotensive in the 80?s resolved
after .... .... .... </p>
<p>Lab at discharge: Glucose 112, BUN 16, creatinine 1.1, electrolytes
normal. H. pylori antibody pending. Admission hematocrit 16%,
discharge hematocrit 29%. WBC 7300, platelet count 256,000.
Urinalysis normal. Urine culture: No growth. INR 1.1, PTT 40. </p>
<p>He was transfused with 6 units of packed red blood cells with ....
.... .... </p>
<p>GI evaluation 12 September: Colonoscopy showed single red clot in
.... ........ </p>
</div>
</text>
</section>
<section>
<title value="Family History Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10157-6"/>
<display value="History of family member diseases Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
</section>
<section>
<title value="Social History Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="29762-2"/>
<display value="Social history Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
<entry>
<reference value="Observation/observation-smoker"/>
</entry>
</section>
<section>
<title value="Functional Status Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="47420-5"/>
<display value="Functional status assessment note"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
</section>
<section>
<title value="General Status Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10210-3"/>
<display value="Physical findings of General status Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Alert and in good spirits, no acute distress.</p>
</div>
</text>
</section>
<section>
<title value="Mental Status Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10190-7"/>
<display value="Mental status"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table border="1" width="100%">
<thead>
<tr>
<td>
<b>Mental Status Findings</b>
</td>
<td>
<b>Effective Dates</b>
</td>
<td>
<b>Condition Status</b>
</td>
</tr>
</thead>
<tr>
<td>Mental Function</td>
<td>July 31, 2013</td>
<td>Impaired</td>
</tr>
<tr>
<td>Cognitive Abilities</td>
<td>July 31, 2013</td>
<td>Judgement, Intact</td>
</tr>
<tr>
<td>Cognitive Function</td>
<td>July 31, 2013</td>
<td>Aggressive Behavior</td>
</tr>
<tr>
<td>Cognitive Function</td>
<td>July 31, 2013</td>
<td>Difficulty understanding own emotions</td>
</tr>
<tr>
<td>Cognitive Function</td>
<td>July 31, 2013</td>
<td>Difficulty communicating Thoughts </td>
</tr>
</table>
</div>
</text>
</section>
<section>
<title value="Medical Equipment Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="46264-8"/>
<display value="History of medical device use"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
</section>
<section>
<title value="Medication Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10160-0"/>
<display value="History of Medication use Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
<entry>
<reference value="MedicationStatement/medication-statement"/>
</entry>
</section>
<section>
<title value="Payers Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="48768-6"/>
<display value="Payment sources Document"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
</section>
<section>
<title value="Plan of Treatment Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="18776-5"/>
<display value="Plan of care note"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>2016/08/16 - 2016/08/16</td>
<td>Completed</td>
</tr>
<tr>
<td>Recommendation to Exercise</td>
<td>2016/10/29</td>
<td>Ongoing</td>
</tr>
</table>
</div>
</text>
</section>
<section>
<title value="Problem Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11450-4"/>
<display value="Problem list - Reported"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
<entry>
<reference value="Condition/condition-problem"/>
</entry>
</section>
<section>
<title value="Procedures Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="47519-4"/>
<display value="History of Procedures Document"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
<entry>
<reference value="Procedure/procedure-rehab"/>
</entry>
</section>
<section>
<title value="Discharge Diagnosis Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11535-2"/>
<display value="Hospital discharge Dx Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Diverticula of intestine</p>
</div>
</text>
</section>
<!-- <section>
<title value="Discharge Medications Section (entries required)"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10183-2"/>
<display value="Hospital discharge medications"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>Acetaminophen Tab 325 mg</td>
<td>Take 2 tablet(s) every four hours if needed</td>
<td>20150615</td>
<td>Active</td>
<td>Pain management</td>
<td>Generic substitution allowed</td>
</tr>
</table>
</div>
</text>
</section> -->
<section>
<title value="Immunizations Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11369-6"/>
<display value="History of Immunization Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
<entry>
<reference value="Immunization/immunization"/>
</entry>
</section>
<section>
<title value="Nutrition Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="61144-2"/>
<display value="Diet and nutrition Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
</section>
<section>
<title value="Reason for Referral Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="42349-1"/>
<display value="Reason for referral (narrative)"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Colonoscopy</p>
</div>
</text>
</section>
<section>
<title value="Results Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="30954-2"/>
<display value="Relevant diagnostic tests/laboratory data Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>2016/06/15</td>
<td>Final</td>
</tr>
</table>
</div>
</text>
<entry>
<reference value="Observation/observation-lab-urine"/>
</entry>
</section>
<section>
<title value="Vital Signs Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="8716-3"/>
<display value="Vital signs"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>2016/06/15</td>
<td>39 Degrees Celcius</td>
</tr>
</table>
</div>
</text>
<entry>
<reference value="Observation/observation-vitals-temp"/>
</entry>
</section>
</Composition>
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
Links: Table of Contents |
QA Report
| Version History |
|
Propose a change