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 
<Composition xmlns="http://hl7.org/fhir">
<id value="Med-2-Dental-Referral"/>
<meta>
<versionId value="25"/>
<lastUpdated value="2021-08-26T17:48:27.238+00:00"/>
<source value="#D3muhSqHq8nuVF61"/>
<profile
value="http://hl7.org/fhir/us/dental-data-exchange/StructureDefinition/dental-referral-note"/>
</meta>
<language value="en-US"/>
<text>
<status value="generated"/>
<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>
</text>
<identifier>
<system value="urn:ietf:rfc:3986"/>
<value value="http://any.org/1"/>
</identifier>
<status value="final"/>
<type>
<coding>
<system value="http://loinc.org"/>
<code value="57134-9"/>
<display value="Dentistry Referral note"/>
</coding>
</type>
<subject>
<reference value="Patient/example-dental"/>
<display value="Patient A"/>
</subject>
<encounter>
<reference value="Encounter/Med-visit-1"/>
<display value="PCP visit"/>
</encounter>
<date value="2020-01-14T03:10:14Z"/>
<author>
<reference value="Practitioner/practitioner-M"/>
<display value="Dr. John M, MD"/>
</author>
<title value="Referral Note"/>
<attester>
<mode value="legal"/>
<time value="2020-03-14T09:10:14Z"/>
<party>
<reference value="PractitionerRole/PractitionerRole-M"/>
<display value="Dr. John M, MD"/>
</party>
</attester>
<custodian>
<reference value="Organization/GHC-organization"/>
<display value="Good Health Clinic"/>
</custodian>
<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>Allergen</b>
</td>
<td>
<b>Code</b>
</td>
<td>
<b>Manifestation</b>
</td>
<td>
<b>Severity</b>
</td>
</tr>
<tr>
<td>Penicillin G</td>
<td>7908</td>
<td>Skin rash</td>
<td>mild</td>
</tr>
</table>
</div>
</text>
<entry>
<reference value="AllergyIntolerance/Allergy-example-dental"/>
</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>Lisinopril 10 mg tab</td>
<td>1 tab once/day</td>
<td/>
<td>Active</td>
<td/>
<td>Generic substitution allowed</td>
</tr>
</table>
</div>
</text>
<entry>
<reference value="MedicationRequest/Lisinopril-medreq"/>
</entry>
</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>Teeth covered in plague</p>
<p>Toothache</p>
<p>Swollen Gums</p>
<p>Bleeding Gums</p>
<p>At high risk for dental carries</p>
</div>
</text>
<entry>
<reference value="Condition/HTN-example"/>
</entry>
<entry>
<reference value="Condition/DM1-example"/>
</entry>
<entry>
<reference value="Condition/Dental-plaque-example"/>
</entry>
<entry>
<reference value="Condition/toothache-example"/>
</entry>
<entry>
<reference value="Condition/Swollen-gums-example"/>
</entry>
<entry>
<reference value="Condition/Bleeding-gums-example"/>
</entry>
<entry>
<reference value="Condition/Caries-risk"/>
</entry>
</section>
<section>
<title value="Reason for Referral Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="42349-1"/>
<display value="Reason for referral (narrative)"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Toothache</p>
<p>Left lower quadrant pain</p>
<p>Bleeding gums</p>
</div>
</text>
<entry>
<reference value="ServiceRequest/example-dental-referral-1"/>
</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">
<p>D0150 - Comprehensive Oral Evaluation</p>
</div>
</text>
<entry>
<reference value="Encounter/Comp-oral-eval"/>
</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 has pain in his lower left jaw and occassional bleeding from his gums - referring for dental evaluation.</p>
</div>
</text>
</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 flouride treatments in the past 4 years while away at college</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="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">
<p>No Procedures performed</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</td>
<td>NA</td>
<td>2005/05/01 - 2020/03/28</td>
</tr>
<tr>
<td>Highest Education Received</td>
<td>Collect Education</td>
<td>2010/05/01 - 2014/03/28</td>
</tr>
<tr>
<td>Employment</td>
<td>Full-time accountant</td>
<td>2015/05/01 - current</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>
<tr>
<td>
<b>Vital Sign</b>
</td>
<td>
<b>Date</b>
</td>
<td>
<b>Value</b>
</td>
</tr>
<tr>
<td>Temperature</td>
<td>2020/04/15</td>
<td>98.5</td>
</tr>
<tr>
<td>Heart Rate</td>
<td>2020/04/15</td>
<td>78</td>
</tr>
<tr>
<td>Respiration Rate</td>
<td>2020/04/15</td>
<td>20</td>
</tr>
<tr>
<td>Blood Pressure</td>
<td>2020/04/15</td>
<td>120/80</td>
</tr>
</table>
</div>
</text>
<entry>
<reference value="Observation/vitals-panel"/>
</entry>
</section>
<section>
<title value="Goals Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="61146-7"/>
<display value="Goals"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>No soda/sugary drinks/energy drinks</p>
<p>Use fluoride toothpaste</p>
</div>
</text>
</section>
<section>
<title value="Health Concerns Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="75310-3"/>
<display value="Health concerns Document"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Neuropathy due to diabetes mellitus</p>
</div>
</text>
</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>Pt. Education. Advised to see dentist regularly, brush 2x/day w/ fluoride
toothpaste, floss</p>
</div>
</text>
<entry>
<reference value="Communication/dental-education"/>
</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">
<p>No Information</p>
</div>
</text>
</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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