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 
@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 "Med-2-Dental-Referral"];
fhir:Resource.meta [
fhir:Meta.versionId [ fhir:value "25" ];
fhir:Meta.lastUpdated [ fhir:value "2021-08-26T17:48:27.238+00:00"^^xsd:dateTime ];
fhir:Meta.source [ fhir:value "#D3muhSqHq8nuVF61" ];
fhir:Meta.profile [
fhir:value "http://hl7.org/fhir/us/dental-data-exchange/StructureDefinition/dental-referral-note";
fhir:index 0;
fhir:link <http://hl7.org/fhir/us/dental-data-exchange/StructureDefinition/dental-referral-note> ]
];
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\" xml:lang=\"en-US\" lang=\"en-US\"><p><b>Generated Narrative</b></p><p><b>identifier</b>: id: http://any.org/1</p><p><b>status</b>: final</p><p><b>type</b>: <span title=\"Codes: {http://loinc.org 57134-9}\">Dentistry Referral note</span></p><p><b>encounter</b>: <a href=\"Encounter-Med-visit-1.html\">PCP visit. Generated Summary: status: finished; <span title=\"{http://terminology.hl7.org/CodeSystem/v3-ActCode AMB}\">ambulatory</span>; <span title=\"Codes: {http://www.ama-assn.org/go/cpt 99201}\">Office Visit</span>; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-ActPriority R}\">routine</span>; period: Feb 14, 2020 8:00:14 PM --> Feb 14, 2020 8:30:14 PM</a></p><p><b>date</b>: Jan 14, 2020 3:10:14 AM</p><p><b>author</b>: <a href=\"Practitioner-practitioner-M.html\">Dr. John M, MD. Generated Summary: id: 1234569999; John M ; Phone: 303-303-6443; gender: male; birthDate: 1975-06-09</a></p><p><b>title</b>: Referral 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 14, 2020 9:10:14 AM</td><td><a href=\"PractitionerRole-PractitionerRole-M.html\">Dr. John M, MD. Generated Summary: <span title=\"Codes: {http://snomed.info/sct 394814009}\">General practice (specialty)</span>; Phone: 5555557777</a></td></tr></table><p><b>custodian</b>: <a href=\"Organization-GHC-organization.html\">Good Health Clinic. Generated Summary: id: 1316452725; active: true; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/organization-type prov}\">Healthcare Provider</span>; name: Good Health Clinic; Phone: (+1) 555-677-7777, customer-service@GHclinic.org</a></p></div>"
];
fhir:Composition.identifier [
fhir:Identifier.system [ fhir:value "urn:ietf:rfc:3986" ];
fhir:Identifier.value [ fhir:value "http://any.org/1" ]
];
fhir:Composition.status [ fhir:value "final"];
fhir:Composition.type [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:57134-9;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "57134-9" ];
fhir:Coding.display [ fhir:value "Dentistry Referral note" ] ]
];
fhir:Composition.subject [
fhir:Reference.reference [ fhir:value "Patient/example-dental" ];
fhir:Reference.display [ fhir:value "Patient A" ]
];
fhir:Composition.encounter [
fhir:Reference.reference [ fhir:value "Encounter/Med-visit-1" ];
fhir:Reference.display [ fhir:value "PCP visit" ]
];
fhir:Composition.date [ fhir:value "2020-01-14T03:10:14Z"^^xsd:dateTime];
fhir:Composition.author [
fhir:index 0;
fhir:Reference.reference [ fhir:value "Practitioner/practitioner-M" ];
fhir:Reference.display [ fhir:value "Dr. John M, MD" ]
];
fhir:Composition.title [ fhir:value "Referral Note"];
fhir:Composition.attester [
fhir:index 0;
fhir:Composition.attester.mode [ fhir:value "legal" ];
fhir:Composition.attester.time [ fhir:value "2020-03-14T09:10:14Z"^^xsd:dateTime ];
fhir:Composition.attester.party [
fhir:Reference.reference [ fhir:value "PractitionerRole/PractitionerRole-M" ];
fhir:Reference.display [ fhir:value "Dr. John M, MD" ] ]
];
fhir:Composition.custodian [
fhir:Reference.reference [ fhir:value "Organization/GHC-organization" ];
fhir:Reference.display [ fhir:value "Good Health Clinic" ]
];
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 Document" ] ] ];
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>Allergen</b>\n </td>\n <td>\n <b>Code</b>\n </td>\n <td>\n <b>Manifestation</b>\n </td>\n <td>\n <b>Severity</b>\n </td>\n </tr>\n <tr>\n <td>Penicillin G</td>\n <td>7908</td>\n <td>Skin rash</td>\n <td>mild</td>\n </tr>\n </table>\n </div>" ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "AllergyIntolerance/Allergy-example-dental" ] ]
], [
fhir:index 1;
fhir:Composition.section.title [ fhir:value "Medication Section" ];
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:10160-0;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "10160-0" ];
fhir:Coding.display [ fhir:value "History of Medication use Narrative" ] ] ];
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>Lisinopril 10 mg tab</td>\n <td>1 tab once/day</td>\n <td/>\n <td>Active</td>\n <td/>\n <td>Generic substitution allowed</td>\n </tr>\n </table>\n </div>" ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "MedicationRequest/Lisinopril-medreq" ] ]
], [
fhir:index 2;
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 - Reported" ] ] ];
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "generated" ];
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Mild, Hypertension</p>\n <p>Type 1 diabetes</p>\n <p>Teeth covered in plague</p>\n <p>Toothache</p>\n <p>Swollen Gums</p>\n <p>Bleeding Gums</p>\n <p>At high risk for dental carries</p>\n </div>" ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "Condition/HTN-example" ] ], [
fhir:index 1;
fhir:Reference.reference [ fhir:value "Condition/DM1-example" ] ], [
fhir:index 2;
fhir:Reference.reference [ fhir:value "Condition/Dental-plaque-example" ] ], [
fhir:index 3;
fhir:Reference.reference [ fhir:value "Condition/toothache-example" ] ], [
fhir:index 4;
fhir:Reference.reference [ fhir:value "Condition/Swollen-gums-example" ] ], [
fhir:index 5;
fhir:Reference.reference [ fhir:value "Condition/Bleeding-gums-example" ] ], [
fhir:index 6;
fhir:Reference.reference [ fhir:value "Condition/Caries-risk" ] ]
], [
fhir:index 3;
fhir:Composition.section.title [ fhir:value "Reason for Referral Section" ];
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:42349-1;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "42349-1" ];
fhir:Coding.display [ fhir:value "Reason for referral (narrative)" ] ] ];
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "generated" ];
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Toothache</p>\n <p>Left lower quadrant pain</p>\n <p>Bleeding gums</p>\n </div>" ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "ServiceRequest/example-dental-referral-1" ] ]
], [
fhir:index 4;
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 care note" ] ] ];
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "generated" ];
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>D0150 - Comprehensive Oral Evaluation</p>\n </div>" ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "Encounter/Comp-oral-eval" ] ]
], [
fhir:index 5;
fhir:Composition.section.title [ fhir:value "Assessment Section" ];
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:51848-0;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "51848-0" ];
fhir:Coding.display [ fhir:value "Evaluation note" ] ] ];
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "generated" ];
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Patient has pain in his lower left jaw and occassional bleeding from his gums - referring for dental evaluation.</p>\n </div>" ]
], [
fhir:index 6;
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 Narrative" ] ] ];
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "generated" ];
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>The patient has not visited a dentist or received flouride treatments in the past 4 years while away at college</p>\n </div>" ]
], [
fhir:index 7;
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 Narrative" ] ] ];
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>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>" ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "Immunization/imm-1" ] ]
], [
fhir:index 8;
fhir:Composition.section.title [ fhir:value "Medical Equipment Section" ];
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:46264-8;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "46264-8" ];
fhir:Coding.display [ fhir:value "History of medical device use" ] ] ];
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>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>" ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "Procedure/Insulin-pump-insertion" ] ]
], [
fhir:index 9;
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 Document" ] ] ];
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "generated" ];
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>No Procedures performed</p>\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 Narrative" ] ] ];
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 Status</td>\n <td>NA</td>\n <td>2005/05/01 - 2020/03/28</td>\n </tr>\n <tr>\n <td>Highest Education Received</td>\n <td>Collect Education</td>\n <td>2010/05/01 - 2014/03/28</td>\n </tr>\n <tr>\n <td>Employment</td>\n <td>Full-time accountant</td>\n <td>2015/05/01 - current</td>\n </tr>\n </table>\n </div>" ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "Observation/Smoker-obs-example-dental" ] ], [
fhir:index 1;
fhir:Reference.reference [ fhir:value "Observation/Education-level-example-dental" ] ], [
fhir:index 2;
fhir:Reference.reference [ fhir:value "Observation/Present-job-example-dental" ] ]
], [
fhir:index 11;
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>2020/04/15</td>\n <td>98.5</td>\n </tr>\n <tr>\n <td>Heart Rate</td>\n <td>2020/04/15</td>\n <td>78</td>\n </tr>\n <tr>\n <td>Respiration Rate</td>\n <td>2020/04/15</td>\n <td>20</td>\n </tr>\n <tr>\n <td>Blood Pressure</td>\n <td>2020/04/15</td>\n <td>120/80</td>\n </tr>\n </table>\n </div>" ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "Observation/vitals-panel" ] ]
], [
fhir:index 12;
fhir:Composition.section.title [ fhir:value "Goals Section" ];
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:61146-7;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "61146-7" ];
fhir:Coding.display [ fhir:value "Goals" ] ] ];
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "generated" ];
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>No soda/sugary drinks/energy drinks</p>\n <p>Use fluoride toothpaste</p>\n </div>" ]
], [
fhir:index 13;
fhir:Composition.section.title [ fhir:value "Health Concerns Section" ];
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:75310-3;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "75310-3" ];
fhir:Coding.display [ fhir:value "Health concerns Document" ] ] ];
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "generated" ];
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Neuropathy due to diabetes mellitus</p>\n </div>" ]
], [
fhir:index 14;
fhir:Composition.section.title [ fhir:value "Instructions Section" ];
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:69730-0;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "69730-0" ];
fhir:Coding.display [ fhir:value "Instructions" ] ] ];
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "generated" ];
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Pt. Education. Advised to see dentist regularly, brush 2x/day w/ fluoride\n toothpaste, floss</p>\n </div>" ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "Communication/dental-education" ] ]
], [
fhir:index 15;
fhir:Composition.section.title [ fhir:value "Payers Section" ];
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:48768-6;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "48768-6" ];
fhir:Coding.display [ fhir:value "Payment sources Document" ] ] ];
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "generated" ];
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Aetna Comprehensive Medical /Dental Insurance</p>\n </div>" ];
fhir:Composition.section.entry [
fhir:index 0;
fhir:Reference.reference [ fhir:value "Coverage/Dental-Aetna" ] ]
], [
fhir:index 16;
fhir:Composition.section.title [ fhir:value "Dental Findings Section" ];
fhir:Composition.section.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:8704-9;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "8704-9" ];
fhir:Coding.display [ fhir:value "Physical findings of Mouth and Throat and Teeth" ] ] ];
fhir:Composition.section.text [
fhir:Narrative.status [ fhir:value "generated" ];
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>No Information</p>\n </div>" ]
].
# - ontology header ------------------------------------------------------------
a owl:Ontology;
owl:imports fhir:fhir.ttl.
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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