This page is part of the C-CDA on FHIR Implementation Guide (v1.0.0: STU 1) based on FHIR R3. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions
{ "resourceType" : "Composition", "id" : "CCDA-on-FHIR-Continuity-of-Care-Document-Example", "meta" : { "profile" : [ "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Continuity-of-Care-Document" ] }, "language" : "en-US", "text" : { "status" : "generated", "div" : "<div xmlns="http://www.w3.org/1999/xhtml"> <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">Summary of Episode 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">Summary of Episode</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">Ambulatory 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>" }, "identifier" : { "system" : "urn:ietf:rfc:3986", "value" : "urn:uuid:7e63fe21-7285-46c6-b72f-e58a61341195" }, "status" : "preliminary", "type" : { "coding" : [ { "system" : "http://loinc.org", "code" : "34133-9", "display" : "Summary of episode note" } ] }, "subject" : { "reference" : "Patient/patient-1", "display" : "Amy V. Shaw" }, "date" : "2016-02-28T09:10:14Z", "author" : [ { "reference" : "Practitioner/practitioner-1", "display" : "Ronald Boone, MD" } ], "title" : "Continuity of Care Document", "confidentiality" : "N", "attester" : [ { "mode" : [ "legal" ], "time" : "2016-06-15T09:10:14Z", "party" : { "reference" : "Practitioner/practitioner-1", "display" : "Ronald Boone, MD" } } ], "custodian" : { "reference" : "Organization/organization-1", "display" : "Community Health and Hospitals" }, "event" : [ { "code" : [ { "coding" : [ { "system" : "http://hl7.org/fhir/v3/ActClass", "code" : "PCPR", "display" : "Care Provision" } ] } ], "period" : { "start" : "2016-06-15", "end" : "2016-08-20" } } ], "section" : [ { "title" : "Allergies and Intolerances Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "48765-2", "display" : "Allergies and adverse reactions" } ] }, "text" : { "status" : "generated", "div" : "<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>" }, "mode" : "snapshot", "orderedBy" : { "coding" : [ { "system" : "http://hl7.org/fhir/list-order", "code" : "event-date", "display" : "Sorted by Event Date" } ] }, "entry" : [ { "reference" : "AllergyIntolerance/allergy-intolerance" } ] }, { "title" : "Medication Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "10160-0", "display" : "History of Medication Use" } ] }, "text" : { "status" : "generated", "div" : "<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>2016/02/28</td> <td>Active</td> <td>Pneumonia</td> <td>Generic substitution allowed</td> </tr> </table> </div>" }, "entry" : [ { "reference" : "MedicationStatement/medication-statement" } ] }, { "title" : "Problem Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "11450-4", "display" : "Problem list" } ] }, "text" : { "status" : "generated", "div" : "<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>2016/02/28</td> <td>2016/03/01</td> <td>Complete</td> </tr> </table> </div>" }, "entry" : [ { "reference" : "Condition/condition-problem" } ] }, { "title" : "Procedures Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "47519-4", "display" : "History of procedures" } ] }, "text" : { "status" : "generated", "div" : "<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>2016/06/15</td> <td>Generalized abdominal pain 24 hours. Localized in RIF with rebound and guarding</td> </tr> </table> </div>" }, "entry" : [ { "reference" : "Procedure/procedure-rehab" } ] }, { "title" : "Results Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "30954-2", "display" : "Relevant diagnostic tests and laboratory data" } ] }, "text" : { "status" : "generated", "div" : "<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>" }, "entry" : [ { "reference" : "Observation/observation-lab-urine" } ] }, { "title" : "Advance Directives Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "42348-3", "display" : "Advance directives" } ] }, "text" : { "status" : "generated", "div" : "<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>2010/01/01 - 2025/01/01</td> </tr> </table> </div>" } }, { "title" : "Encounters Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "46240-8", "display" : "Encounters" } ] }, "text" : { "status" : "generated", "div" : "<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>2016/04/18</td> </tr> </table> </div>" } }, { "title" : "Family History Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "10157-6", "display" : "History of family member diseases" } ] }, "text" : { "status" : "generated", "div" : "<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>" } }, { "title" : "Functional Status Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "47420-5", "display" : "Functional status assessment" } ] }, "text" : { "status" : "generated", "div" : "<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>2016/06/15</td> <td>Active</td> </tr> <tr> <td>Finding of Functional Performance and Activity</td> <td>Dyspnea</td> <td>2016/06/15</td> <td>Active</td> </tr> <tr> <td>Cognitive Function Finding</td> <td>Memory Impairment</td> <td>2010/04/17</td> <td>Active</td> </tr> </table> </div>" } }, { "title" : "Immunizations Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "11369-6", "display" : "History of immunization" } ] }, "text" : { "status" : "generated", "div" : "<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>2014/05/29</td> <td>Completed</td> </tr> </table> </div>" }, "entry" : [ { "reference" : "Immunization/immunization" } ] }, { "title" : "Nutrition Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "61144-2", "display" : "Diet and nutrition" } ] }, "text" : { "status" : "generated", "div" : "<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>2016/06/15</td> <td>Well nourished</td> <td>Low sodium diet, excessive carbohydrate</td> </tr> <tr> <td>2016/06/15</td> <td>Slight dehydration</td> <td>High protein, low fibre</td> </tr> </table> </div>" } }, { "title" : "Mental Status Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "10190-7", "display" : "Mental status" } ] }, "text" : { "status" : "generated", "div" : "<div xmlns="http://www.w3.org/1999/xhtml"> <table> <tr> <td> <b>Date</b> </td> <td> <b>Mental Status</b> </td> <td> <b>Support System</b> </td> </tr> <tr> <td>2016/06/15</td> <td>Good</td> <td>Not required</td> </tr> <tr> <td>2012/04/29</td> <td>Dimentia</td> <td>Daily Home Care</td> </tr> </table> </div>" } }, { "title" : "Social History Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "29762-2", "display" : "Social history" } ] }, "text" : { "status" : "generated", "div" : "<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>2010/01/01 - 2016/06/15</td> </tr> </table> </div>" }, "entry" : [ { "reference" : "Observation/observation-smoker" } ] }, { "title" : "Plan of Treatment Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "18776-5", "display" : "Plan of treatment" } ] }, "text" : { "status" : "generated", "div" : "<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>2016/06/15 - 2015/06/15</td> <td>Completed</td> </tr> <tr> <td>Recommendation to Exercise</td> <td>2016/06/15</td> <td>Ongoing</td> </tr> </table> </div>" } }, { "title" : "Payers Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "48768-6", "display" : "Payers" } ] }, "text" : { "status" : "generated", "div" : "<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>" } }, { "title" : "Medical Equipment Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "46264-8", "display" : "Medical equipment" } ] }, "text" : { "status" : "generated", "div" : "<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>2015/05/29</td> </tr> <tr> <td>Wheelchair</td> <td>2016/06/15</td> </tr> </table> </div>" } }, { "title" : "Vital Signs Section", "code" : { "coding" : [ { "system" : "http://loinc.org", "code" : "8716-3", "display" : "Vital signs" } ] }, "text" : { "status" : "generated", "div" : "<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>" }, "entry" : [ { "reference" : "Observation/observation-vitals-temp" } ] } ] }