C-CDA on FHIR Implementation Guide STU 1 (v1.0.0)
This page is part of the C-CDA on FHIR Implementation Guide (v1.0.0: STU 1) based on FHIR R3. This is the current published version. For a full list of available versions, see the Directory of published versions 
@prefix fhir: <http://hl7.org/fhir/> . @prefix loinc: <http://loinc.org/rdf#> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- a fhir:Composition; fhir:nodeRole fhir:treeRoot; fhir:Resource.id [ fhir:value "CCDA-on-FHIR-Discharge-Summary-Example"]; fhir:Resource.meta [ fhir:Meta.versionId [ fhir:value "1" ]; fhir:Meta.lastUpdated [ fhir:value "2016-06-15T08:16:14Z"^^xsd:dateTime ]; fhir:Meta.profile [ fhir:value "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Discharge-Summary"; fhir:index 0 ] ]; fhir:Resource.language [ fhir:value "en-US"]; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\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\">Discharge Summary</span>\n </td>\n <td class=\"td_header_role_value\">Discharge Summary for Amy 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<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1003<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 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\">Encounter Type</span>\n </td>\n <td class=\"td_header_role_value\">Discharge</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 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\">Inpatient Unit at 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<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1003<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<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<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<br/>Amherst MA 01003, US<br/>Tel: (555)555-1212<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<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<br/>Amherst MA 01003, US<br/>Tel: (555)555-1215<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<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1003<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 </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<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1003<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<br/>Portland, OR 99123, US<br/>Tel: +1(555)555-1215<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<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1666<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 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<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1003<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 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<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1003<br/>\n </td>\n </tr>\n </tbody>\n </table>\n </div>" ]; fhir:Composition.identifier [ fhir:Identifier.system [ fhir:value "urn:ietf:rfc:3986" ]; fhir:Identifier.value [ fhir:value "1" ] ]; fhir:Composition.status [ fhir:value "preliminary"]; fhir:Composition.type [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:18842-5; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "18842-5" ]; fhir:Coding.display [ fhir:value "Discharge Summary" ] ] ]; fhir:Composition.subject [ fhir:Reference.reference [ fhir:value "Patient/patient-1" ]; fhir:Reference.display [ fhir:value "Amy V. Shaw" ] ]; fhir:Composition.date [ fhir:value "2016-02-28T09:10:14Z"^^xsd:dateTime]; fhir:Composition.author [ fhir:index 0; fhir:Reference.reference [ fhir:value "Practitioner/practitioner-1" ]; fhir:Reference.display [ fhir:value "Ronald Boone, MD" ] ]; fhir:Composition.title [ fhir:value "Discharge Summary(CCoF)"]; fhir:Composition.confidentiality [ fhir:value "N"]; fhir:Composition.custodian [ fhir:Reference.reference [ fhir:value "Organization/organization-1" ]; fhir:Reference.display [ fhir:value "Community Health and Hospitals" ] ]; fhir:Composition.section [ fhir:index 0; fhir:Composition.section.title [ fhir:value "Allergies and Intolerances Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:48765-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "48765-2" ]; fhir:Coding.display [ fhir:value "Allergies and adverse reactions" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Substance</b>\n </td>\n <td>\n <b>Overall Severity</b>\n </td>\n <td>\n <b>Reaction</b>\n </td>\n <td>\n <b>Reaction Severity</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Cashew Nut</td>\n <td>Severe</td>\n <td>Anaphylactic reaction</td>\n <td>Mild</td>\n <td>Active</td>\n </tr>\n </table>\n </div>" ]; fhir:Composition.section.mode [ fhir:value "snapshot" ]; fhir:Composition.section.orderedBy [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/list-order" ]; fhir:Coding.code [ fhir:value "event-date" ]; fhir:Coding.display [ fhir:value "Sorted by Event Date" ] ] ]; fhir:Composition.section.entry [ fhir:index 0; fhir:Reference.reference [ fhir:value "AllergyIntolerance/allergy-intolerance" ] ] ], [ fhir:index 1; fhir:Composition.section.title [ fhir:value "Chief Complaint and Reason for Visit Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:46239-0; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "46239-0" ]; fhir:Coding.display [ fhir:value "Chief complaint and reason for visit" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Cramping, bloating, and constipation.</p>\n </div>" ] ], [ fhir:index 2; fhir:Composition.section.title [ fhir:value "Chief Complaint Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:10154-3; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "10154-3" ]; fhir:Coding.display [ fhir:value "Chief complaint" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Dark Stools</p>\n </div>" ] ], [ fhir:index 3; fhir:Composition.section.title [ fhir:value "Reason for Visit Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:29299-5; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "29299-5" ]; fhir:Coding.display [ fhir:value "Reason for visit" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Tenderness of lower abdomen</p>\n </div>" ] ], [ fhir:index 4; fhir:Composition.section.title [ fhir:value "Admission Diagnosis Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:46241-6; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "46241-6" ]; fhir:Coding.display [ fhir:value "Hospital admission diagnosis" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Appendicitis</p>\n </div>" ] ], [ fhir:index 5; fhir:Composition.section.title [ fhir:value "Admission Medications Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:42346-7; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "42346-7" ]; fhir:Coding.display [ fhir:value "Medications on admission" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Medication</b>\n </td>\n <td>\n <b>Directions</b>\n </td>\n <td>\n <b>Start Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n <td>\n <b>Indications</b>\n </td>\n <td>\n <b>Fill Instructions</b>\n </td>\n </tr>\n <tr>\n <td>Pepcid Complete (MAGNESIUM HYDROXIDE0</td>\n <td>Chew one tablet completely and swallow as needed </td>\n <td>20160615</td>\n <td>Active</td>\n <td>Bloating</td>\n <td>Generic substitution allowed</td>\n </tr>\n </table>\n </div>" ] ], [ fhir:index 6; fhir:Composition.section.title [ fhir:value "History of Past Illness Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:11348-0; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "11348-0" ]; fhir:Coding.display [ fhir:value "History of past illness" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Problem Name</b>\n </td>\n <td>\n <b>Type</b>\n </td>\n <td>\n <b>Onset Date</b>\n </td>\n <td>\n <b>Abatement Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Fever</td>\n <td>Condition</td>\n <td>2016-06-15</td>\n <td>2016-06-15</td>\n <td>Complete</td>\n </tr>\n </table>\n </div>" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:Reference.reference [ fhir:value "Condition/condition-problem" ] ] ], [ fhir:index 7; fhir:Composition.section.title [ fhir:value "History of Present Illness Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:10164-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "10164-2" ]; fhir:Coding.display [ fhir:value "History of present illness" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>This patient was only recently discharged for a recurrent GI bleed as described below. </p>\n <p>He presented to the ER today c/o a dark stool yesterday but a normal brown\n stool today. On exam he was hypotensive in the 80?s resolved after .... .... .... </p>\n <p>Lab at discharge: Glucose 112, BUN 16, creatinine 1.1, electrolytes normal.\n H. pylori antibody pending. Admission hematocrit 16%, discharge hematocrit 29%. WBC\n 7300, platelet count 256,000. Urinalysis normal. Urine culture: No growth. INR 1.1,\n PTT 40. </p>\n <p>He was transfused with 6 units of packed red blood cells with .... .... .... </p>\n <p>GI evaluation 12 September: Colonoscopy showed single red clot in .... ........ </p>\n </div>" ] ], [ fhir:index 8; fhir:Composition.section.title [ fhir:value "Review of Systems Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:10187-3; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "10187-3" ]; fhir:Coding.display [ fhir:value "Review of systems" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Patient denies recent history of fever or malaise. Positive for weakness and\n shortness of breath. One episode of melena. No recent headaches. Positive for\n osteoarthritis in hips, knees and hands. </p>\n </div>" ] ], [ fhir:index 9; fhir:Composition.section.title [ fhir:value "Family History Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:10157-6; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "10157-6" ]; fhir:Coding.display [ fhir:value "History of family member diseases" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Relationship</b>\n </td>\n <td>\n <b>Diagnosis</b>\n </td>\n <td>\n <b>Age at Onset</b>\n </td>\n </tr>\n <tr>\n <td>Father</td>\n <td>Myocardial Infarction(cause of Death)</td>\n <td>57</td>\n </tr>\n <tr>\n <td>Father</td>\n <td>Diabetes</td>\n <td>40</td>\n </tr>\n </table>\n </div>" ] ], [ fhir:index 10; fhir:Composition.section.title [ fhir:value "Social History Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:29762-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "29762-2" ]; fhir:Coding.display [ fhir:value "Social history" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Social History Element</b>\n </td>\n <td>\n <b>Description</b>\n </td>\n <td>\n <b>Effective Dates</b>\n </td>\n </tr>\n <tr>\n <td>Smoking</td>\n <td>1 pack tobacco per day</td>\n <td>2005/05/01 - 2010/02/28</td>\n </tr>\n </table>\n </div>" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:Reference.reference [ fhir:value "Observation/observation-smoker" ] ] ], [ fhir:index 11; fhir:Composition.section.title [ fhir:value "Functional Status Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:47420-5; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "47420-5" ]; fhir:Coding.display [ fhir:value "Functional status" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Functional or Cognitive Finding</b>\n </td>\n <td>\n <b>Observation</b>\n </td>\n <td>\n <b>Observation Date</b>\n </td>\n <td>\n <b>Condition Status</b>\n </td>\n </tr>\n <tr>\n <td>Ambulation (Dependent to Independent</td>\n <td>Independently able</td>\n <td>2010/03/11</td>\n <td>Active</td>\n </tr>\n <tr>\n <td>Finding of Functional Performance and Activity</td>\n <td>Dyspnea</td>\n <td>2008/02/16</td>\n <td>Active</td>\n </tr>\n <tr>\n <td>Cognitive Function Finding</td>\n <td>Memory Impairment</td>\n <td>2014/04/29</td>\n <td>Active</td>\n </tr>\n </table>\n </div>" ] ], [ fhir:index 12; fhir:Composition.section.title [ fhir:value "Hospital Course Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:8648-8; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "8648-8" ]; fhir:Coding.display [ fhir:value "Hospital course" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Following a colonoscopy, the patient was admitted and started on Lovenox and\n nitroglycerin paste. The patient had serial cardiac enzymes and was ruled out for\n myocardial infarction. The patient underwent a dual isotope stress test. There was no\n evidence of reversible ischemia on the Cardiolite scan. The patient has been ambulated.\n The patient had a Holter monitor placed but the report is not available at this time.\n The patient has remained hemodynamically stable. Will discharge.</p>\n </div>" ] ], [ fhir:index 13; fhir:Composition.section.title [ fhir:value "Hospital Consultations Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:18841-7; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "18841-7" ]; fhir:Coding.display [ fhir:value "Hospital consultations" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>listType="ordered"</p>\n <p>Gastroenterology</p>\n <p>Cardiology</p>\n <p>Dietitian</p>\n </div>" ] ], [ fhir:index 14; fhir:Composition.section.title [ fhir:value "Plan of Treatment Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:18776-5; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "18776-5" ]; fhir:Coding.display [ fhir:value "Plan of treatment" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.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>2016/08/16 - 2016/08/16</td>\n <td>Completed</td>\n </tr>\n <tr>\n <td>Recommendation to Exercise</td>\n <td>2016/06/29</td>\n <td>Ongoing</td>\n </tr>\n </table>\n </div>" ] ], [ fhir:index 15; fhir:Composition.section.title [ fhir:value "Problem Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:11450-4; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "11450-4" ]; fhir:Coding.display [ fhir:value "Problem list" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Problem Name</b>\n </td>\n <td>\n <b>Type</b>\n </td>\n <td>\n <b>Onset Date</b>\n </td>\n <td>\n <b>Abatement Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Fever</td>\n <td>Condition</td>\n <td>2016-04-01</td>\n <td>2016-04-14</td>\n <td>Complete</td>\n </tr>\n </table>\n </div>" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:Reference.reference [ fhir:value "Condition/condition-problem" ] ] ], [ fhir:index 16; fhir:Composition.section.title [ fhir:value "Procedures Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:47519-4; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "47519-4" ]; fhir:Coding.display [ fhir:value "History of procedures" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Procedure Name</b>\n </td>\n <td>\n <b>Body Site</b>\n </td>\n <td>\n <b>Performer</b>\n </td>\n <td>\n <b>Date Performed</b>\n </td>\n <td>\n <b>Reason</b>\n </td>\n </tr>\n <tr>\n <td>Appendectomy (Procedure)</td>\n <td>Abdomen</td>\n <td>Dr. Adam Everyman</td>\n <td>20160405</td>\n <td>Generalized abdominal pain 24 hours. Localized in RIF with rebound and guarding</td>\n </tr>\n </table>\n </div>" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:Reference.reference [ fhir:value "Procedure/procedure-rehab" ] ] ], [ fhir:index 17; fhir:Composition.section.title [ fhir:value "Discharge Diagnosis Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:11535-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "11535-2" ]; fhir:Coding.display [ fhir:value "Hospital discharge diagnosis" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Diverticula of intestine</p>\n </div>" ] ], [ fhir:index 18; fhir:Composition.section.title [ fhir:value "Discharge Medications Section (entries required)" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:10183-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "10183-2" ]; fhir:Coding.display [ fhir:value "Hospital discharge medications" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Medication</b>\n </td>\n <td>\n <b>Directions</b>\n </td>\n <td>\n <b>Start Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n <td>\n <b>Indications</b>\n </td>\n <td>\n <b>Fill Instructions</b>\n </td>\n </tr>\n <tr>\n <td>Acetaminophen Tab 325 mg</td>\n <td>Take 2 tablet(s) every four hours if needed</td>\n <td>20160618</td>\n <td>Active</td>\n <td>Pain management</td>\n <td>Generic substitution allowed</td>\n </tr>\n </table>\n </div>" ] ], [ fhir:index 19; fhir:Composition.section.title [ fhir:value "Hospital Discharge Instructions Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:8653-8; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "8653-8" ]; fhir:Coding.display [ fhir:value "Hospital discharge instructions" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Take all of your prescription medication as directed. </p>\n <p>Make an appointment with your doctor to be seen two weeks from the date of your procedure. </p>\n <p>You may feel slightly bloated after the procedure because of air that was\n introduced during the examination. </p>\n <p> Call your physician if you notice: \n <br/> Bleeding or black stools. \n <br/> Abdominal pain. \n <br/> Fever or chills. \n <br/> Nausea or vomiting. \n <br/> Any unusual pain or problem. \n <br/> Pain or redness at the site where the intravenous needle was placed. \n <br/>\n </p>\n <p>Do not drink alcohol for 24 hours. Alcohol amplifies the effect of the sedatives given. </p>\n <p>Do not drive or operate machinery for 24 hours.</p>\n </div>" ] ], [ fhir:index 20; fhir:Composition.section.title [ fhir:value "Hospital Discharge Physical Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:10184-0; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "10184-0" ]; fhir:Coding.display [ fhir:value "Hospital discharge physical" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>GENERAL: Well-developed, slightly obese man. </p>\n <p>NECK: Supple, with no jugular venous distension.</p>\n <p>HEART: Intermittent tachycardia without murmurs or gallops. </p>\n <p>PULMONARY: Decreased breath sounds, but no clear-cut rales or wheezes.</p>\n <p>EXTREMITIES: Free of edema.</p>\n </div>" ] ], [ fhir:index 21; fhir:Composition.section.title [ fhir:value "Hospital Discharge Studies Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:11493-4; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "11493-4" ]; fhir:Coding.display [ fhir:value "Hospital discharge studies summary" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Laboratory Information</th>\n <th>Chemistries and drug levels</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>Potasium</td>\n <td>4.0</td>\n </tr>\n <tr>\n <td>NA (135-145meq/l)</td>\n <td>140</td>\n </tr>\n </tbody>\n </table>\n <br/>\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Other Tests</th>\n <th>Results</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>EKG</td>\n <td>Sinus rhythm without acute changes.</td>\n </tr>\n </tbody>\n </table>\n </div>" ] ], [ fhir:index 22; fhir:Composition.section.title [ fhir:value "Immunizations Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:11369-6; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "11369-6" ]; fhir:Coding.display [ fhir:value "History of immunization" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Vaccine</b>\n </td>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Fluvax (Influenza)</td>\n <td>2016-04-05</td>\n <td>Completed</td>\n </tr>\n </table>\n </div>" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:Reference.reference [ fhir:value "Immunization/immunization" ] ] ], [ fhir:index 23; fhir:Composition.section.title [ fhir:value "Nutrition Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:61144-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "61144-2" ]; fhir:Coding.display [ fhir:value "Diet and nutrition" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Nutritional Status</b>\n </td>\n <td>\n <b>Diet</b>\n </td>\n </tr>\n <tr>\n <td>2016/06/15</td>\n <td>Well nourished</td>\n <td>Low sodium diet, excessive carbohydrate</td>\n </tr>\n <tr>\n <td>2016/06/15</td>\n <td>Slight dehydration</td>\n <td>High protein, low fibre</td>\n </tr>\n </table>\n </div>" ] ], [ fhir:index 24; fhir:Composition.section.title [ fhir:value "Vital Signs Section" ]; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:8716-3; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "8716-3" ]; fhir:Coding.display [ fhir:value "Vital signs" ] ] ]; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Vital Sign</b>\n </td>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Value</b>\n </td>\n </tr>\n <tr>\n <td>Temperature</td>\n <td>2016/06/15</td>\n <td>39 Degrees Celcius</td>\n </tr>\n </table>\n </div>" ]; fhir:Composition.section.entry [ fhir:index 0; fhir:Reference.reference [ fhir:value "Observation/observation-vitals-temp" ] ] ]. # - ontology header ------------------------------------------------------------ a owl:Ontology; owl:imports fhir:fhir.ttl.
© HL7.org 2011+. C-CDA on FHIR Implementation Guide v1.0.0 based on FHIR version (v3.0.1) generated on
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