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. 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="CCDA-on-FHIR-Progress-Note-Example"/> <meta> <versionId value="1"/> <lastUpdated value="2016-06-15T08:16:14Z"/> <profile value="http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Progress-Note"/> </meta> <language value="en-US"/> <text> <status value="generated"/> <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">Progress Note 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">Progress Assessment</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 Sept 18, 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 Unit 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="1"/> </identifier> <status value="preliminary"/> <type> <coding> <system value="http://loinc.org"/> <code value="11506-3"/> <display value="Provider-unspecified Progress note"/> </coding> </type> <!-- Patient Resource --> <subject> <reference value="Patient/patient-1"/> <display value="Amy V. Shaw"/> </subject> <date value="2016-02-28T09:10:14Z"/> <!-- Practitioner Resource --> <author> <reference value="Practitioner/practitioner-1"/> <display value="Ronald Boone, MD"/> </author> <title value="Progress Note"/> <confidentiality value="N"/> <attester> <mode value="legal"/> <time value="2012-01-04T09:10:14Z"/> <party> <reference value="Practitioner/practitioner-1"/> <display value="Ronald Boone, MD"/> </party> </attester> <!-- Organization Resource --> <custodian> <reference value="Organization/organization-1"/> <display value="Community Health and Hospitals"/> </custodian> <event> <code> <coding> <system value="http://hl7.org/fhir/v3/ActClass"/> <code value="PCPR"/> <display value="Care Provision"/> </coding> </code> <period> <start value="2016-06-15"/> </period> </event> <!-- Encounter Resource --> <!-- <encounter><reference value="http://fhirtest.uhn.ca/baseDstu3/Encounter/117630"/></encounter> --> <!-- Allergies and Intolerances Section Narrative --> <section> <title value="Allergies and Intolerances Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="48765-2"/> <display value="Allergies and adverse reactions"/> </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> <mode value="snapshot"/> <orderedBy> <coding> <system value="http://hl7.org/fhir/list-order"/> <code value="event-date"/> <display value="Sorted by Event Date"/> </coding> </orderedBy> <!-- Allergies and Intolerances Section Resource --> <entry> <reference value="AllergyIntolerance/allergy-intolerance"/> </entry> </section> <!-- Assessment Section Narrative --> <section> <title value="Assessment Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="51848-0"/> <display value="Assessment (evaluation)"/> </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> <!-- Assessment and Plan Section Narrative --> <section> <title value="Assessment and Plan Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="51847-2"/> <display value="Assessment (evaluation) and plan"/> </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> <!-- Chief Complaint Section Narrative --> <section> <title value="Chief Complaint Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="10154-3"/> <display value="Chief complaint"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Dark Stools</p> </div> </text> </section> <!-- Instructions Section Narrative --> <section> <title value="Instructions Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="69730-0"/> <display value="Instructions"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Patient may have low grade fever, mild joint pain and injection area tenderness.</p> </div> </text> </section> <!-- Interventions Section Narrative --> <section> <title value="Interventions Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="62387-6"/> <display value="Interventions provided"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tr> <td> <b>Planned Intervention</b> </td> <td> <b>Status</b> </td> <td> <b>Date</b> </td> </tr> <tr> <td>Elevate head of bed</td> <td>active</td> <td>September 2, 2016</td> </tr> <tr> <td>Oxygen administration by nasal cannula</td> <td>active</td> <td>September 1, 2016</td> </tr> <tr> <td>pulse oximetry monitoring</td> <td>active</td> <td>September 3, 2016</td> </tr> </table> </div> </text> </section> <!-- Nutrition Section Narrative --> <section> <title value="Nutrition Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="61144-2"/> <display value="Diet and nutrition"/> </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> <!-- Physical Exam Section Narrative --> <section> <title value="Physical Exam Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="29545-1"/> <display value="Physical findings"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>HEENT: All normal to examination.</p> <p>>HEART: RRR, no murmur.</p> <p>THORAX & LUNGS: Clear without rhonchi or wheeze.</p> <p>ABDOMEN: Marked distension and tenderness, slightly obese, pos bowelsounds.</p> <p>BACK: Normal to inspection and palpation, without tenderness; no presacral edema.</p> <p>EXTREMITIES: Doughy edema bilaterally, chronic stasis changes, no asymmetrical swelling.</p> </div> </text> </section> <!-- Objective Section Narrative --> <section> <title value="Objective Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="61149-1"/> <display value="Objective"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Chest: clear to ausc. No rales, normal breath sounds</p> <p>Heart: RR, PMI in normal location and no heave or evidence ofcardiomegaly,normal heart sounds, no murm or gallop</p> </div> </text> </section> <!-- Subjective Section Narrative --> <section> <title value="Subjective Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="61150-9"/> <display value="Subjective"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Complaints of rectal bleeding, fatigue and a change in bowel patterns.</p> <p>Has several days of constipation alternating with diarrhea.</p> </div> </text> </section> <!-- Review of Systems Section Narrative --> <section> <title value="Review of Systems Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="10187-3"/> <display value="Review of systems"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Patient denies recent history of fever or malaise. Positive for weakness and shortness of breath. Several episodes of abdominal tenderness. No recent headaches. Positive for osteoarthritis in hips, knees and hands. </p> </div> </text> </section> <!-- Medication Section Narrative --> <section> <title value="Medication Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="10160-0"/> <display value="History of Medication Use"/> </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> <!-- Medication Section Resource --> <entry> <reference value="MedicationStatement/medication-statement"/> </entry> </section> <!-- Plan of Treatment Section Narrative --> <section> <title value="Plan of Treatment Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="18776-5"/> <display value="Plan of treatment"/> </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>2010/08/16 - 2010/08/16</td> <td>Completed</td> </tr> <tr> <td>Recommendation to Exercise</td> <td>2015/10/29</td> <td>Ongoing</td> </tr> </table> </div> </text> </section> <!-- Problem Section Narrative --> <section> <title value="Problem Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="11450-4"/> <display value="Problem list"/> </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> <!-- Problem Section Condition Resource --> <entry> <reference value="Condition/condition-problem"/> </entry> </section> <!-- Results Section Narrative --> <section> <title value="Results Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="30954-2"/> <display value="Relevant diagnostic tests and laboratory data"/> </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> <!-- Results Section Observation Resource --> <entry> <reference value="Observation/observation-lab-urine"/> </entry> </section> <!-- Vital Signs Section Narrative --> <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> <!-- Vital Signs Section Observation Resource --> <entry> <reference value="Observation/observation-vitals-temp"/> </entry> </section> </Composition>
© HL7.org 2011+. C-CDA on FHIR Implementation Guide v1.0.0 based on FHIR version (v3.0.1) generated on
Sat, Apr 7, 2018 06:53+1000. QA Page
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