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 in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions 
{
"resourceType" : "Composition",
"id" : "Dental-2-Med-Consult",
"meta" : {
"versionId" : "24",
"lastUpdated" : "2021-08-24T23:27:45.426+00:00",
"source" : "#sBPqj3BhYLw4XXH8",
"profile" : [
"http://hl7.org/fhir/us/dental-data-exchange/StructureDefinition/dental-consult-note"
]
},
"language" : "en-US",
"text" : {
"status" : "extensions",
"div" : "<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>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension",
"valueReference" : {
"reference" : "ServiceRequest/example-dental-referral-1"
}
}
],
"identifier" : {
"system" : "urn:ietf:rfc:3986",
"value" : "urn:uuid:f28fefc8-5aac-427c-93d7-f0bc7d633a9b"
},
"status" : "final",
"type" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "34756-7",
"display" : "Dentistry Consult note"
}
]
},
"subject" : {
"reference" : "Patient/example-dental",
"display" : "Patient A"
},
"encounter" : {
"reference" : "Encounter/Dental-encounter",
"display" : "Dental Referral with patient A"
},
"date" : "2020-02-16T09:10:14Z",
"author" : [
{
"reference" : "Practitioner/practitioner-D",
"display" : "Dentist D, DMD"
}
],
"title" : "Consultation Note",
"attester" : [
{
"mode" : "legal",
"time" : "2020-03-28T09:10:14Z",
"party" : {
"reference" : "Practitioner/practitioner-D",
"display" : "Dentist Dentist D, DMD"
}
}
],
"custodian" : {
"reference" : "Organization/GOHC-organization",
"display" : "Good Oral Health Clinic"
},
"event" : [
{
"code" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-ActClass",
"code" : "PCPR",
"display" : "Care Provision"
}
]
}
],
"period" : {
"start" : "2020-02-16",
"end" : "2020-02-16"
}
}
],
"section" : [
{
"title" : "Allergies and Intolerances Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "48765-2",
"display" : "Allergies and adverse reactions Document"
}
]
},
"text" : {
"status" : "generated",
"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>Penicillin G (Ingredient)</td>\n <td>Mild</td>\n <td>Skin rash</td>\n <td>Mild</td>\n <td>Active</td>\n </tr>\n </table>\n </div>"
},
"entry" : [
{
"reference" : "AllergyIntolerance/Allergy-example-dental"
}
]
},
{
"title" : "History of Present Illness Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10164-2",
"display" : "History of Present illness Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>The patient has not visited a dentist or received fluoride treatments in the past four years while away at college</p>\n </div>"
}
},
{
"title" : "Problem Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11450-4",
"display" : "Problem list - Reported"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Mild, Hypertension</p>\n <p>Type 1 diabetes</p>\n <p>Dental caries</p>\n <p>Unable to chew</p>\n <p>Teeth covered in plague</p>\n <p>Toothache</p>\n <p>Chronic periodontitis</p>\n <p>Infection of tooth</p>\n <p>At high risk for dental caries (finding)</p>\n </div>"
},
"entry" : [
{
"reference" : "Condition/HTN-example"
},
{
"reference" : "Condition/DM1-example"
},
{
"reference" : "Condition/Dental-caries"
},
{
"reference" : "Condition/no-chew"
},
{
"reference" : "Condition/Dental-plaque-example"
},
{
"reference" : "Condition/toothache-example"
},
{
"reference" : "Condition/Chronic-periodontitis-example"
},
{
"reference" : "Condition/Tooth-infection18"
},
{
"reference" : "Condition/Caries-risk"
}
]
},
{
"title" : "Medication Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10160-0",
"display" : "History of Medication use Narrative"
}
]
},
"text" : {
"status" : "generated",
"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>erythromycin 500 mg</td>\n <td>Take 1 tablet every six hours X10 days</td>\n <td/>\n <td>Active</td>\n <td/>\n <td/>\n </tr>\n <tr>\n <td>ibuprofen (OTC) 200 mg tab</td>\n <td>Take 2-3 tablets every 8 hours as needed for pain</td>\n <td>Take 2-3 tablets every 8 hours as needed for pain</td>\n <td/>\n <td>Active</td>\n <td/>\n <td/>\n </tr>\n <tr>\n <td>acetaminophen (OTC) 325 mg</td>\n <td>Take 2 tablets every 4-6 hours as needed for pain</td>\n <td/>\n <td>Active</td>\n <td/>\n <td/>\n </tr>\n <tr>\n <td>Lisinopril 10 mg tab</td>\n <td>1 tab once a day</td>\n <td/>\n <td>Active</td>\n <td/>\n <td/>\n </tr>\n </table>\n </div>"
},
"entry" : [
{
"reference" : "MedicationRequest/erythromycin-medreq-2"
},
{
"reference" : "MedicationRequest/Ibuprofen-medreq-2"
},
{
"reference" : "MedicationRequest/Tylenol-med-dental"
},
{
"reference" : "MedicationRequest/Lisinopril-medreq"
}
]
},
{
"title" : "Assessment Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "51848-0",
"display" : "Evaluation note"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p> Patient reports inability to chew on left side due to pain and\n sensitivity, a condition that has increased in severity in the two days\n since his medical appointment </p>\n <p> Significant decay on the left lower second molar (tooth #18)\n with signs of infection </p>\n <p> Early signs of a caries lesion (decay) on the right upper\n lateral incisor (tooth #7) </p>\n <p> Recommend an extraction of the left lower second molar(tooth\n #18) and a restoration on the right upper lateral incisor (tooth #7) due\n to a caries lesion </p>\n </div>"
}
},
{
"title" : "Immunizations Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11369-6",
"display" : "History of Immunization Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Vaccine</th>\n <th>Date</th>\n <th>Status</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>\n Hepatitis B vaccine\n </td>\n <td>January 4, 2020</td>\n <td>Completed</td>\n </tr>\n </tbody>\n </table>\n </div>"
},
"entry" : [
{
"reference" : "Immunization/imm-1"
}
]
},
{
"title" : "Medical Equipment Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "46264-8",
"display" : "History of medical device use"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Device Type</th>\n <th>Procedure</th>\n <th>Implant Date</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>Insulin Pump</td>\n <td>Insertion of insulin pump (procedure)</td>\n <td>November 3, 2013</td>\n </tr>\n </tbody>\n </table>\n </div>"
},
"entry" : [
{
"reference" : "Procedure/Insulin-pump-insertion"
}
]
},
{
"title" : "Plan of Treatment Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "18776-5",
"display" : "Plan of care note"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Date</th>\n <th>Code</th>\n <th>Description</th>\n <th>Mouth Location</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>Feb 23, 2020</td>\n <td>D7140</td>\n <td>Extraction, erupted tooth or exposed root (elevation and/or\n forceps removal)</td>\n <td>Tooth #18</td>\n </tr>\n <tr>\n <td>Mar 3, 2020</td>\n <td>D1352</td>\n <td>Preventive resin restoration in a moderate to high caries\n risk patient-permanent tooth</td>\n <td>Tooth #7</td>\n </tr>\n <tr>\n <td>Mar 10, 2020</td>\n <td>D0150</td>\n <td>comprehensive oral evaluation - new or established\n patient</td>\n <td>N/A</td>\n </tr>\n <tr>\n <td>Mar 10, 2020</td>\n <td>D1110</td>\n <td>Prophylaxis - Adult</td>\n <td>N/A</td>\n </tr>\n <tr>\n <td>Mar 10, 2020</td>\n <td>D0210</td>\n <td>Full mouth radiographic survey</td>\n <td>N/A</td>\n </tr>\n </tbody>\n </table>\n </div>"
},
"entry" : [
{
"reference" : "ServiceRequest/Dental-extraction-example"
},
{
"reference" : "ServiceRequest/Resin-restore-example"
},
{
"reference" : "ServiceRequest/prophylaxis-example"
},
{
"reference" : "ServiceRequest/Radiograph-survey"
}
]
},
{
"title" : "Procedures Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "47519-4",
"display" : "History of Procedures Document"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Date</th>\n <th>Code</th>\n <th>Description</th>\n <th>Mouth Location</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>Feb 16, 2020</td>\n <td>D1206</td>\n <td>topical application of fluoride varnish</td>\n <td>N/A</td>\n </tr>\n </tbody>\n </table>\n </div>"
},
"entry" : [
{
"reference" : "Procedure/Dental-flouride-tx-example"
}
]
},
{
"title" : "Reason for Visit Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29299-5",
"display" : "Reason for visit"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Patient referred for evaluation and treatment for toothache lower left</p>\n </div>"
}
},
{
"title" : "Social History Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29762-2",
"display" : "Social history Narrative"
}
]
},
"text" : {
"status" : "generated",
"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 Status - Meaningful Use</td>\n <td>Never smoked tobacco</td>\n <td>Feb 14, 2020</td>\n </tr>\n <tr>\n <td>Highest Education Level</td>\n <td>College Education</td>\n <td>2005/05/01 - 2010/02/28</td>\n </tr>\n <tr>\n <td>Employment</td>\n <td>Accountaint, Full Time</td>\n <td>2005/05/01 - 2010/02/28</td>\n </tr>\n </table>\n </div>"
},
"entry" : [
{
"reference" : "Observation/Smoker-obs-example-dental"
},
{
"reference" : "Observation/Education-level-example-dental"
},
{
"reference" : "Observation/Present-job-example-dental"
}
]
},
{
"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\">\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Observation Type</th>\n <th>Value</th>\n <th>Units</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>Body Temperature</td>\n <td>99</td>\n <td>[degF]</td>\n </tr>\n <tr>\n <td>Heart Rate</td>\n <td>82</td>\n <td>/min</td>\n </tr>\n <tr>\n <td>Blood Pressure - Diastolic</td>\n <td>80</td>\n <td>mmHg</td>\n </tr>\n <tr>\n <td>Blood Pressure - Systolic</td>\n <td>120</td>\n <td>mmHg</td>\n </tr>\n </tbody>\n </table>\n </div>"
},
"entry" : [
{
"reference" : "Observation/body-temperature"
},
{
"reference" : "Observation/heart-rate"
},
{
"reference" : "Observation/blood-pressure"
}
]
},
{
"title" : "Instructions Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "69730-0",
"display" : "Instructions"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Patient educated on the benefits of using a fluoride toothpaste, daily\n flossing, and bi-annual routine dental cleaning visits.</p>\n </div>"
},
"entry" : [
{
"reference" : "Communication/dental-education2"
}
]
},
{
"title" : "Payers Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "48768-6",
"display" : "Payment sources Document"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Aetna Comprehensive Medical /Dental Insurance</p>\n </div>"
},
"entry" : [
{
"reference" : "Coverage/Dental-Aetna"
}
]
},
{
"title" : "Dental Findings Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8704-9",
"display" : "Physical findings of Mouth and Throat and Teeth"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Finding Type</th>\n <th>Value</th>\n <th>Location</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>Problem</td>\n <td>Dental Caries</td>\n <td>Tooth #18</td>\n </tr>\n <tr>\n <td>Problem</td>\n <td>Infection of Tooth</td>\n <td>Tooth #18</td>\n </tr>\n <tr>\n <td>Problem</td>\n <td>Dental Caries</td>\n <td>Tooth #7</td>\n </tr>\n <tr>\n <td>Result</td>\n <td>Overjet</td>\n <td>3mm</td>\n </tr>\n </tbody>\n </table>\n </div>"
},
"entry" : [
{
"reference" : "Condition/Mandibular-perm18-example"
},
{
"reference" : "Condition/Tooth-infection18"
},
{
"reference" : "Condition/Maxillary-perm7-example"
},
{
"reference" : "Observation/Overjet"
}
]
}
]
}
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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