Dental Data Exchange
1.0.0 - STU 1
Dental Data Exchange
1.0.0 - STU 1
This page is part of the Dental Data Exchange (v1.0.0: STU1) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions 
<Composition xmlns="http://hl7.org/fhir">
<id value="Dental-2-Med-Consult"/>
<meta>
<versionId value="24"/>
<lastUpdated value="2021-08-24T23:27:45.426+00:00"/>
<source value="#sBPqj3BhYLw4XXH8"/>
<profile
value="http://hl7.org/fhir/us/dental-data-exchange/StructureDefinition/dental-consult-note"/>
</meta>
<language value="en-US"/>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US"><p><b>Generated Narrative</b></p><p><b>Order Extension</b>: <a href="ServiceRequest-example-dental-referral-1.html">Generated Summary: id: urn:uid:0c2aacfc-ce7d-4652-b9ea-7280ea21dec4; status: active; intent: plan; <span title="Codes: {http://snomed.info/sct 14736009}">Evaluation and management of patient (procedure)</span>; priority: asap; <span title="Codes: {http://snomed.info/sct 103697008}">Patient referral for dental care (procedure)</span></a></p><p><b>identifier</b>: id: urn:uuid:f28fefc8-5aac-427c-93d7-f0bc7d633a9b</p><p><b>status</b>: final</p><p><b>type</b>: <span title="Codes: {http://loinc.org 34756-7}">Dentistry Consult note</span></p><p><b>encounter</b>: <a href="Encounter-Dental-encounter.html">Dental Referral with patient A. Generated Summary: status: finished; <span title="{http://terminology.hl7.org/CodeSystem/v3-ActCode AMB}">ambulatory</span>; <span title="Codes: {http://snomed.info/sct 185347001}">Encounter for problem (procedure)</span>; <span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-ActPriority R}">routine</span>; period: Feb 16, 2020 8:00:14 PM --> Feb 16, 2020 8:30:14 PM</a></p><p><b>date</b>: Feb 16, 2020 9:10:14 AM</p><p><b>author</b>: <a href="Practitioner-practitioner-D.html">Dentist D, DMD. Generated Summary: id: 1234560000; John D ; Phone: 720-555-6443; gender: male; birthDate: 1990-06-09</a></p><p><b>title</b>: Consultation Note</p><h3>Attesters</h3><table class="grid"><tr><td>-</td><td><b>Mode</b></td><td><b>Time</b></td><td><b>Party</b></td></tr><tr><td>*</td><td>legal</td><td>Mar 28, 2020 9:10:14 AM</td><td><a href="Practitioner-practitioner-D.html">Dentist Dentist D, DMD. Generated Summary: id: 1234560000; John D ; Phone: 720-555-6443; gender: male; birthDate: 1990-06-09</a></td></tr></table><p><b>custodian</b>: <a href="Organization-GOHC-organization.html">Good Oral Health Clinic. Generated Summary: id: 2316452725; active: true; <span title="Codes: {http://terminology.hl7.org/CodeSystem/organization-type prov}">Healthcare Provider</span>; name: Good Oral Health Clinic; Phone: (+1) 720-677-7777, customer2-service@GHclinic.org</a></p><h3>Events</h3><table class="grid"><tr><td>-</td><td><b>Code</b></td><td><b>Period</b></td></tr><tr><td>*</td><td><span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-ActClass PCPR}">Care Provision</span></td><td>2020-02-16 --> 2020-02-16</td></tr></table></div>
</text>
<extension
url="http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension">
<valueReference>
<reference value="ServiceRequest/example-dental-referral-1"/>
</valueReference>
</extension>
<identifier>
<system value="urn:ietf:rfc:3986"/>
<value value="urn:uuid:f28fefc8-5aac-427c-93d7-f0bc7d633a9b"/>
</identifier>
<status value="final"/>
<type>
<coding>
<system value="http://loinc.org"/>
<code value="34756-7"/>
<display value="Dentistry Consult note"/>
</coding>
</type>
<subject>
<reference value="Patient/example-dental"/>
<display value="Patient A"/>
</subject>
<encounter>
<reference value="Encounter/Dental-encounter"/>
<display value="Dental Referral with patient A"/>
</encounter>
<date value="2020-02-16T09:10:14Z"/>
<author>
<reference value="Practitioner/practitioner-D"/>
<display value="Dentist D, DMD"/>
</author>
<title value="Consultation Note"/>
<attester>
<mode value="legal"/>
<time value="2020-03-28T09:10:14Z"/>
<party>
<reference value="Practitioner/practitioner-D"/>
<display value="Dentist Dentist D, DMD"/>
</party>
</attester>
<custodian>
<reference value="Organization/GOHC-organization"/>
<display value="Good Oral Health Clinic"/>
</custodian>
<event>
<code>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v3-ActClass"/>
<code value="PCPR"/>
<display value="Care Provision"/>
</coding>
</code>
<period>
<start value="2020-02-16"/>
<end value="2020-02-16"/>
</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>Penicillin G (Ingredient)</td>
<td>Mild</td>
<td>Skin rash</td>
<td>Mild</td>
<td>Active</td>
</tr>
</table>
</div>
</text>
<entry>
<reference value="AllergyIntolerance/Allergy-example-dental"/>
</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>The patient has not visited a dentist or received fluoride treatments in the past four years while away at college</p>
</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">
<p>Mild, Hypertension</p>
<p>Type 1 diabetes</p>
<p>Dental caries</p>
<p>Unable to chew</p>
<p>Teeth covered in plague</p>
<p>Toothache</p>
<p>Chronic periodontitis</p>
<p>Infection of tooth</p>
<p>At high risk for dental caries (finding)</p>
</div>
</text>
<entry>
<reference value="Condition/HTN-example"/>
</entry>
<entry>
<reference value="Condition/DM1-example"/>
</entry>
<entry>
<reference value="Condition/Dental-caries"/>
</entry>
<entry>
<reference value="Condition/no-chew"/>
</entry>
<entry>
<reference value="Condition/Dental-plaque-example"/>
</entry>
<entry>
<reference value="Condition/toothache-example"/>
</entry>
<entry>
<reference value="Condition/Chronic-periodontitis-example"/>
</entry>
<entry>
<reference value="Condition/Tooth-infection18"/>
</entry>
<entry>
<reference value="Condition/Caries-risk"/>
</entry>
</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>erythromycin 500 mg</td>
<td>Take 1 tablet every six hours X10 days</td>
<td/>
<td>Active</td>
<td/>
<td/>
</tr>
<tr>
<td>ibuprofen (OTC) 200 mg tab</td>
<td>Take 2-3 tablets every 8 hours as needed for pain</td>
<td>Take 2-3 tablets every 8 hours as needed for pain</td>
<td/>
<td>Active</td>
<td/>
<td/>
</tr>
<tr>
<td>acetaminophen (OTC) 325 mg</td>
<td>Take 2 tablets every 4-6 hours as needed for pain</td>
<td/>
<td>Active</td>
<td/>
<td/>
</tr>
<tr>
<td>Lisinopril 10 mg tab</td>
<td>1 tab once a day</td>
<td/>
<td>Active</td>
<td/>
<td/>
</tr>
</table>
</div>
</text>
<entry>
<reference value="MedicationRequest/erythromycin-medreq-2"/>
</entry>
<entry>
<reference value="MedicationRequest/Ibuprofen-medreq-2"/>
</entry>
<entry>
<reference value="MedicationRequest/Tylenol-med-dental"/>
</entry>
<entry>
<reference value="MedicationRequest/Lisinopril-medreq"/>
</entry>
</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> Patient reports inability to chew on left side due to pain and
sensitivity, a condition that has increased in severity in the two days
since his medical appointment </p>
<p> Significant decay on the left lower second molar (tooth #18)
with signs of infection </p>
<p> Early signs of a caries lesion (decay) on the right upper
lateral incisor (tooth #7) </p>
<p> Recommend an extraction of the left lower second molar(tooth
#18) and a restoration on the right upper lateral incisor (tooth #7) due
to a caries lesion </p>
</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 border="1" width="100%">
<thead>
<tr>
<th>Vaccine</th>
<th>Date</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>
Hepatitis B vaccine
</td>
<td>January 4, 2020</td>
<td>Completed</td>
</tr>
</tbody>
</table>
</div>
</text>
<entry>
<reference value="Immunization/imm-1"/>
</entry>
</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 border="1" width="100%">
<thead>
<tr>
<th>Device Type</th>
<th>Procedure</th>
<th>Implant Date</th>
</tr>
</thead>
<tbody>
<tr>
<td>Insulin Pump</td>
<td>Insertion of insulin pump (procedure)</td>
<td>November 3, 2013</td>
</tr>
</tbody>
</table>
</div>
</text>
<entry>
<reference value="Procedure/Insulin-pump-insertion"/>
</entry>
</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 border="1" width="100%">
<thead>
<tr>
<th>Date</th>
<th>Code</th>
<th>Description</th>
<th>Mouth Location</th>
</tr>
</thead>
<tbody>
<tr>
<td>Feb 23, 2020</td>
<td>D7140</td>
<td>Extraction, erupted tooth or exposed root (elevation and/or
forceps removal)</td>
<td>Tooth #18</td>
</tr>
<tr>
<td>Mar 3, 2020</td>
<td>D1352</td>
<td>Preventive resin restoration in a moderate to high caries
risk patient-permanent tooth</td>
<td>Tooth #7</td>
</tr>
<tr>
<td>Mar 10, 2020</td>
<td>D0150</td>
<td>comprehensive oral evaluation - new or established
patient</td>
<td>N/A</td>
</tr>
<tr>
<td>Mar 10, 2020</td>
<td>D1110</td>
<td>Prophylaxis - Adult</td>
<td>N/A</td>
</tr>
<tr>
<td>Mar 10, 2020</td>
<td>D0210</td>
<td>Full mouth radiographic survey</td>
<td>N/A</td>
</tr>
</tbody>
</table>
</div>
</text>
<entry>
<reference value="ServiceRequest/Dental-extraction-example"/>
</entry>
<entry>
<reference value="ServiceRequest/Resin-restore-example"/>
</entry>
<entry>
<reference value="ServiceRequest/prophylaxis-example"/>
</entry>
<entry>
<reference value="ServiceRequest/Radiograph-survey"/>
</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 border="1" width="100%">
<thead>
<tr>
<th>Date</th>
<th>Code</th>
<th>Description</th>
<th>Mouth Location</th>
</tr>
</thead>
<tbody>
<tr>
<td>Feb 16, 2020</td>
<td>D1206</td>
<td>topical application of fluoride varnish</td>
<td>N/A</td>
</tr>
</tbody>
</table>
</div>
</text>
<entry>
<reference value="Procedure/Dental-flouride-tx-example"/>
</entry>
</section>
<section>
<title value="Reason for Visit Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="29299-5"/>
<display value="Reason for visit"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Patient referred for evaluation and treatment for toothache lower left</p>
</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 Status - Meaningful Use</td>
<td>Never smoked tobacco</td>
<td>Feb 14, 2020</td>
</tr>
<tr>
<td>Highest Education Level</td>
<td>College Education</td>
<td>2005/05/01 - 2010/02/28</td>
</tr>
<tr>
<td>Employment</td>
<td>Accountaint, Full Time</td>
<td>2005/05/01 - 2010/02/28</td>
</tr>
</table>
</div>
</text>
<entry>
<reference value="Observation/Smoker-obs-example-dental"/>
</entry>
<entry>
<reference value="Observation/Education-level-example-dental"/>
</entry>
<entry>
<reference value="Observation/Present-job-example-dental"/>
</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 border="1" width="100%">
<thead>
<tr>
<th>Observation Type</th>
<th>Value</th>
<th>Units</th>
</tr>
</thead>
<tbody>
<tr>
<td>Body Temperature</td>
<td>99</td>
<td>[degF]</td>
</tr>
<tr>
<td>Heart Rate</td>
<td>82</td>
<td>/min</td>
</tr>
<tr>
<td>Blood Pressure - Diastolic</td>
<td>80</td>
<td>mmHg</td>
</tr>
<tr>
<td>Blood Pressure - Systolic</td>
<td>120</td>
<td>mmHg</td>
</tr>
</tbody>
</table>
</div>
</text>
<entry>
<reference value="Observation/body-temperature"/>
</entry>
<entry>
<reference value="Observation/heart-rate"/>
</entry>
<entry>
<reference value="Observation/blood-pressure"/>
</entry>
</section>
<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 educated on the benefits of using a fluoride toothpaste, daily
flossing, and bi-annual routine dental cleaning visits.</p>
</div>
</text>
<entry>
<reference value="Communication/dental-education2"/>
</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">
<p>Aetna Comprehensive Medical /Dental Insurance</p>
</div>
</text>
<entry>
<reference value="Coverage/Dental-Aetna"/>
</entry>
</section>
<section>
<title value="Dental Findings Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="8704-9"/>
<display value="Physical findings of Mouth and Throat and Teeth"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table border="1" width="100%">
<thead>
<tr>
<th>Finding Type</th>
<th>Value</th>
<th>Location</th>
</tr>
</thead>
<tbody>
<tr>
<td>Problem</td>
<td>Dental Caries</td>
<td>Tooth #18</td>
</tr>
<tr>
<td>Problem</td>
<td>Infection of Tooth</td>
<td>Tooth #18</td>
</tr>
<tr>
<td>Problem</td>
<td>Dental Caries</td>
<td>Tooth #7</td>
</tr>
<tr>
<td>Result</td>
<td>Overjet</td>
<td>3mm</td>
</tr>
</tbody>
</table>
</div>
</text>
<entry>
<reference value="Condition/Mandibular-perm18-example"/>
</entry>
<entry>
<reference value="Condition/Tooth-infection18"/>
</entry>
<entry>
<reference value="Condition/Maxillary-perm7-example"/>
</entry>
<entry>
<reference value="Observation/Overjet"/>
</entry>
</section>
</Composition>
IG © 2020+ Payer/Provider Information Exchange Work Group. Package hl7.fhir.us.dental-data-exchange#1.0.0 based on FHIR 4.0.1. Generated 2021-11-02
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